Contaminated Blood and Blood Products

Norman Lamb Excerpts

Thursday 24th November 2016 Commons Chamber

[Christian Matheson (City of Chester) (Lab)]

I commence in the same vein as others by paying tribute to the leadership and work of my hon. Friend the Member for Kingston upon Hull North (Diana Johnson) on this issue. I see other Members across the Chamber today who have also played a part, including the hon. Member for Stratford-on-Avon (Nadhim Zahawi), who has been in meetings with the hon. Member for Worthing West (Sir Peter Bottomley). This is not a party political issue. The core of it is simply about doing the right thing, and it shows all-party groups and Parliament at their best. Members have come together on the basis of the difficult personal stories of our constituents, such as the one we have just heard from the hon. Member for Thirsk and Malton (Kevin Hollinrake).

I have two constituents who have provided me with an inspirational lead in tackling the problem. My constituent Debra has HIV. She received it from a partner who had received contaminated blood products. In fact, he did not tell her at the time, and it took her several years to work out that all her health problems derived from that infection. He obviously became her ex-partner, and that person later died of his illness. Debra has never been able to hold down a job because of the continuing, persistent nature of the illness. In common with the constituent described by the hon. Member for Thirsk and Malton, Debra was asked to leave her job, and her career has been badly threatened.

My constituent Neil has hepatitis C, which he contracted as a haemophilia patient as a child. Again, he is unable to hold down a job, which means he cannot hold on to decent housing. Another aspect of the problem is that Neil’s body retains water, and he has to go regularly to hospital to have his body drained of excess fluid. He can work, but he suffers from fatigue and his whole life has been dominated by these problems.

The only mistake these constituents of mine and of other Members have committed is to be unlucky. That is the only thing they have done. They were unlucky when they received these contaminated blood products or, in the case of Debra, were infected by a partner, without being told the circumstances. They are the victims of what could be considered, as we have said, a crime. We cannot get away from the fact that we still need to do more for people whose basic problem is that they were unlucky at a difficult time in their lives.

The current system is chaotic. We are simplifying it, although I fear that when we simplify systems of this kind, they may also become less valuable. As other Members have said, when it has been simplified and the various schemes have been brought together, no recipient should be any worse off. I approve of such an amalgamation, but I cannot help feeling that so far there has been almost a policy of divide and rule—perhaps unwitting, perhaps deliberate—with different types of scheme for different types of sufferer. There are also different schemes, and different levels of schemes, in the different countries of the United Kingdom. The situation is absurd: someone living in England might qualify for a Scottish scheme because it relates to the country that the recipient was in when he or she was infected.

We need some consistency and fairness. People who, rightly, feel angry and let down are being forced to compare their circumstances with those of other victims rather than looking to the real culprits: the private companies, described so eloquently by my hon. Friend the Member for Kingston upon Hull North, which put profit before patients’ safety all those years ago and have never been brought to account. For that reason, I support the calls for a proper inquiry. I tabled some questions to the Department of Health recently, and it transpires that those corporations have never paid any compensation and no compensation has ever been sought from them. Someone said earlier that it might be difficult to pin down exactly who was responsible and when, but there should at least be an effort to track down those who are responsible and force them to pay for their misdemeanours.

I asked Debra and Neil for their comments. There is no doubt that Debra will lose money under the current proposals. The former Prime Minister, David Cameron, said in the House:

“Today I am proud to provide them with the support that they deserve.”—[Official Report, 13 July 2016; Vol. 613, c. 291.]

Debra found those words rather distasteful. Her response was angry, and she had every right to be angry. She gleaned from what the Prime Minister had said that she, as an HIV-infected partner, deserved to be worse off. She knows that her support will be reduced, but she wants to know what will happen to the money that Macfarlane Trust beneficiaries are losing. Will the amounts be the same? Victims of this scandal who are losing money are being asked to turn in on themselves rather than directing their fire at the real culprits. The Minister can deal with that by ensuring that no one loses out.

Debra believes that the schemes will take financial support from HIV and co-infected victims: those whose condition has no cure, who are forced to take toxic medication that helps to keep them alive, who struggle with mental illnesses as a result of living with stigma and discrimination, and who every day face the reality that, despite medication, people are still dying from HIV and AIDS. Debra has the impression that moving the schemes around is robbing Peter to pay Paul.

Neil supports the idea of a Hillsborough-style inquiry, but says it is important to ensure that the level of support payments is maintained. He says:

“£15,500 is far too low and does not take into account how much expense being ill and travelling to and from hospitals across the country is!”

He also says that the payments should be linked to inflation, because otherwise they will grow ever smaller.

[Norman Lamb (North Norfolk) (LD)]

The hon. Gentleman mentioned a Hillsborough-style inquiry. Like the hon. Member for Kingston upon Hull North (Diana Johnson), I should like the Government to consider that. I took up the case of Ms Sullivan-Weeks’s stepfather, who received unheated Scottish blood products in England after they had been withdrawn in Scotland because there was a time lag in England. We do not know how many people were affected in that way, but he ended up dying. That prompts a particular sense of injustice. Does the hon. Gentleman agree that that is another reason why a Hillsborough-style inquiry is necessary?

[Christian Matheson]

Absolutely. We need to get to the truth. The victims and the surviving members of their families deserve the truth, and the culprits must be held to account as well. As has already been pointed out, it seems that there was knowledge of what was going on at the time.

The right hon. Member for North East Bedfordshire (Alistair Burt) rightly said that this matter is not going to go away. The longer it goes on, and the greater the sense of injustice felt by the victims and their families, the stronger will be the calls for a final resolution. I am glad that the Minister is present, because the Government have an opportunity to do the right thing: to lift the black cloud of uncertainty, and to end what was eloquently described by the right hon. Member for North East Bedfordshire as a “drip, drip” approach. We need a final answer to this question, which will provide the certainty that has been missing for so long.

Social Care

Norman Lamb Excerpts

Wednesday 16th November 2016 Commons Chamber

[Barbara Keeley]

My hon. Friend is right, and I shall come to that point shortly.

Carers UK reports that insufficient support from health and social care services is leaving the carers who are doing all that extra work

“isolated, burnt-out and unable to look after their own health.”

The Richmond Group of Charities published the story of Susan. She cares for her husband Bruce, who has been diagnosed with both Parkinson’s and dementia. The struggle that Susan underwent to find quality care is one about which I have been hearing from carers for some time. She was provided with respite care from a care home which was of such low quality that her husband was unrecognisable when she returned for him:

“He hadn’t been shaved, he couldn’t walk, and his eyes were crusted…with blepharitis.”

When Susan managed to get home care for her husband, it was also poor quality. She said:

“They didn’t know what they were doing. It seemed like they’d never cared before. They turned up at five o’clock in the afternoon to put my husband to bed. Or they turned up at ten, once I’d already helped him to bed. Absolutely awful.”

It is also telling how carers like Susan feel when dealing with the challenges of negotiating complex and fragmented care systems. She “felt small” and she said:

“You go in there, and you’ve got no idea about anything, about care. It’s like going in on the first day at school.”

Susan is not a rare case of a carer battling to get respite care or home care of an acceptable quality. Carers UK tell us that three out of 10 carers in its survey have experienced a change in the amount of care and support services that they receive. Six out of 10 of those carers experiencing a change said the amount of care and support received had been reduced.

[Norman Lamb (North Norfolk) (LD)]

The hon. Lady argues for bringing forward funding, and I agree. Does she agree, however, that that is not enough in itself and that all of us on both sides of the House must confront the chronic underfunding of the health and care system, and we need to find ways to raise significantly more resources to ensure we have a modern and efficient health and care system?

[Barbara Keeley]

I agree, and our motion talks about the need for

“a longer-term settlement to ensure that the social care system is sustainable going forward”.

We absolutely do need that.

On quality of care, I was talking about Susan finding a care home and it giving inadequate care. There are too many such care homes. In its 2016 “State of Care” report, the Care Quality Commission said that when it makes a return visit to a service originally rated as “inadequate”, one quarter of those services were not able to improve their ratings. Susan found poor-quality home care, and last week the ombudsman reported that the number of complaints about homecare is rising and that the number of complaints upheld by the ombudsman is also rising.

--- Later in debate ---

[Toby Perkins]

rose—

[Norman Lamb]

rose—

[Mr Hunt]

I will give way once more now and will then try to give way to everyone during the course of my remarks.

[Mr Hunt]

The hon. Gentleman is absolutely right to make that point. I want to talk about Winterbourne View a little later, because this is not just about older people.

[Norman Lamb]

rose—

[Mr Hunt]

I will give way shortly, but I want to finish my point about the critical role played by care staff. In total, 1.5 million people work in the social care sector, and I want to mention one group in particular: the 90,000 who come from the EU. They do a brilliant job and we value their contribution to the sector.

If the House will forgive me, I want to share one story from early in my time as Health Secretary about an absolutely brilliant manager, who is Polish, of a dementia care home in Swiss Cottage. The people at the home had advanced dementia and many were unable to talk or move, so the atmosphere in the home was challenging to say the least. I asked the lady how she motivated her staff every day, and she said, “If I can get a resident to smile, they won’t remember it the next day, but I do, and I go home with a smile on my face.” The care that was being provided was, to be frank, completely remarkable. This is a moment for all of us to reaffirm what the Prime Minister said today at Prime Minister’s questions: we want these people to remain and we are confident and optimistic that we will be able to get them to remain.

[Mr Hunt]

I will give way to the right hon. Gentleman, but I want to give way first to my former ministerial colleague.

[Norman Lamb]

I totally share the sentiment that EU workers are welcome in our country and that we must guarantee their future as soon as possible.

Does the Secretary of State ever feel that he is confronted by a pretty fundamental choice? He can either preside over a system that deteriorates with an increasing number of failures of care, which I know he cares passionately about, or he can be the politician in government who confronts that, who works with other parties and who comes up with a sustainable long-term solution. It is one or the other. I urge him to take the latter course.

[Mr Hunt]

I absolutely want to be someone in this role who confronts poor care and does everything possible to fight for the highest standards. That is exactly why I am doing this job. Poor care comes in different forms and, yes, funding is an issue. As the health and social care system goes through perhaps its most financially challenging period since the founding of the NHS, I particularly want to ensure that we protect the high standards that the right hon. Gentleman cares about.

Oral Answers to Questions

Norman Lamb Excerpts

Tuesday 15th November 2016 Commons Chamber

[David Mowat]

It is vital that every STP engages with all stakeholders, and that includes North Devon. The public and, indeed, MPs should engage in the process as critical friends to try to make these plans better.

[Norman Lamb (North Norfolk) (LD)]

Despite reassurances, there are still concerns that mental health remains peripheral to STPs in many areas. Will the Minister provide some further reassurance, because unless the Government absolutely insist that mental health is central and that resources are focused on prevention in mental health, these plans will simply fail?

[David Mowat]

I give the right hon. Gentleman the categorical assurance that better mental health is a fundamental part of what the STPs are trying to achieve, as are better cancer outcomes and better integration of adult social care. If an STP does not include those things, it will have to continue to evolve until it does.

Community Pharmacies

Norman Lamb Excerpts

Wednesday 2nd November 2016 Commons Chamber

[David Mowat]

Before I give way, I should like to quote the chief pharmacist himself. Dr Keith Ridge has confirmed that the review

“will support community pharmacy to develop new clinical pharmacy services, working practices and online support to meet the public’s expectations for a modern NHS.”

Two weeks ago, I announced two initiatives that will proceed in advance of the King’s Fund report. From 1 December, phone calls made to NHS 111 for urgent repeat prescriptions will be directed not to an out-of-hours GP service as at present but to a community pharmacy. This will amount to some 200,000 calls a year, resulting in further revenue streams, for the consultations and for supplying the medicine. NHS England has also committed to encouraging national coverage of a locally commissioned NHS minor ailments service. Some areas, including West Yorkshire, already do this, and we will roll it out to the whole country by April 2018. Both those initiatives will relieve pressure on surgeries and emergency care centres. Both will result in additional incremental revenue for pharmacies, but they are very much only the start.

[Norman Lamb (North Norfolk) (LD)]

Does the Minister accept the view expressed in the impact assessment that independent pharmacies, which are often micro-businesses, and small chains of up to 20 pharmacies will be at a higher risk of closure than the larger chains?

[David Mowat]

In terms of these proposals, we have to be blind to the ownership of pharmacies. The fact is that the average pharmacy sells for something like £750,000. I do not accept that the proposals will cause closures in those segments, if that was the thrust of the right hon. Gentleman’s question.

--- Later in debate ---

[David Mowat]

I will continue to make some progress and then give way towards the end of my remarks.

I do not want to downplay the impact of the change on the private businesses that own and operate the network. The pharmacy sector is a mixed economy with 70% of the market made up of multiples and chains and 30% owned by independents. It is hard to accurately predict the impact of the changes on those individual business models. What I can say, however, is that the savings we are making will be entirely recycled back into the NHS. Every penny of the efficiency savings that we are asking of community pharmacies will be spent on better patient care, better drugs and better GP access.

[Norman Lamb]

I am grateful to the Minister for giving way. I totally understand the importance of trying to get as much bang for your buck from pharmacy services, but does this not actually amount to a significant cut in spending on preventive services? That seems completely counter to the Government’s aim.

[David Mowat]

When one takes into account the £112 million that we are spending on getting more pharmacists into GP practices, the right hon. Gentleman’s point is incorrect.

--- Later in debate ---

[Norman Lamb (North Norfolk) (LD)]

My central argument is that this is a cut to preventive healthcare and as such is completely irrational, makes no sense and will be a false economy. It will end up with fewer people accessing pharmacies than at the moment, resulting in more pressure on GPs and A&E departments.

I have made the point to the Government before that, by all means, they should do more to get more bang for their buck, to ensure that money is working effectively and that people get good preventive care in their communities, but they should not cut the budget for preventive care. In response to my earlier intervention, the Minister said that the cut was compensated for by the extra investment in GP practices, but that is misleading because the total investment in GP practices for pharmacies will be £112 million between now and 2020, yet in one year, by 2017-18, this budget will be down by £208 million. It is a massive cut to preventive care. It makes no sense at all and is the precise opposite of what the Government claim they seek to do on shifting resources within the NHS.

[Tim Farron (Westmorland and Lonsdale) (LD)]

When I surveyed pharmacists in my community, they told me, among other things, that in what is probably England’s most rural county, more than 80% of pharmacies do not qualify for the rural pharmacy access scheme, and for those that do, that money will be blown away by the larger cuts. Given that staff are already being laid off, does my right hon. Friend agree that one of the greatest areas of damage will be to small, rural pharmacies in areas such as ours?

[Norman Lamb]

I thank my hon. Friend for making that point; it was the second one that I was going to make. As the hon. Member for Central Ayrshire (Dr Whitford) made clear earlier, the impact will be arbitrary, and disadvantaged communities and rural areas will feel it most. Only four of the 15 pharmacists in my community will benefit from the pharmacy access scheme; all the others will not, yet they are needed by their local community.

[Greg Mulholland]

There were some outrageous comments earlier suggesting that some of those smaller pharmacies are simply there for dispensing, when they have trained pharmacists helping people. As well as the important village and rural pharmacies—I have village pharmacies in Pool and Bramhope that do excellent work—communities in suburbs rely on smaller pharmacies; those communities will lose that service.

[Norman Lamb]

Absolutely. It is the arbitrary impact of the cut that concerns me so much.

The other aspect of that arbitrariness is—again, a point made by the hon. Member for Central Ayrshire—that the big boys will be fine. They will survive. Surely, the Government should be addressing the excess profits of those organisations, rather than putting in danger—as their own impact assessment says—the small independent pharmacies and small chains. It is completely irrational and makes no sense.

The final issue I want to raise is that, instead of going about cutting preventive care, protecting the big boys and putting small pharmacies at risk, the Government ought to be undertaking a major programme to increase what pharmacies do. We heard earlier about what is happening in Scotland; that is the approach that should be taken. There should be more work on smoking cessation, on sexual health, on substance misuse and on screening and immunisation, and more should be done to promote independent living, encourage healthy lifestyles and support people in their self-care.

The Government’s approach makes no sense. The bottom line is that, as the Government scrape around trying to find enough resources to prop up the NHS, which, as we know, is expecting to receive a reducing percentage of our national income between now and 2020, they are making stupid decisions such as cutting spending on health education, on public health and on community pharmacies. The Government are in a complete mess. We need extra resources for the NHS and a new long-term settlement. The sooner the Government recognise that, the better.

NHS Funding

Norman Lamb Excerpts

Monday 31st October 2016 Commons Chamber

[Mr Hunt]

I want to get the exact figures in order to live up to my hon. Friend’s reputation for plain speaking, which is second to none. The NHS budget in 2014-15 will be £98.1 billion and in 2021 it will go up to £119.9 billion. In real terms, that is a £10 billion increase.

[Norman Lamb (North Norfolk) (LD)]

Is there not an urgent need to be straight with the British public about the resources we will need to maintain both the NHS and the care system, and to confront the fact that we will all have to pay a bit more to ensure that our loved ones get care when they need it?

[Mr Hunt]

When the right hon. Gentleman and I worked in government, we both campaigned hard on many occasions for more funding for the NHS, including mental health—a particular priority for both of us. The answer to his question is yes, and that is why we are putting in more money in this Parliament. My own view is that in future Parliaments we will need to continue to increase the amount of funding going in to the NHS. The only point I would make is that what funds the NHS is a strong economy, so we have to make sure that increases in NHS funding are sustainable and compatible with a strong economy. That is something that this Conservative Government have a very good track record of delivering.

Health Service Medical Supplies (Costs) Bill

Norman Lamb Excerpts

2nd reading: House of Commons & Programme motion: House of Commons
Monday 24th October 2016 Commons Chamber

[Mr Hunt]

My hon. Friend is right about that. The nice way of putting it is that we are closing a loophole. If one were being less polite, one might say that it is a shame we are having to do that. None the less, it is important to do what we are proposing to the House.

We recognise that it has been some time since the Government consulted on the options, and I wish to reassure hon. Members and those companies in the statutory scheme that we will consult further on the implementation of a payment mechanism in the statutory scheme, including the level of the payment mechanism, before the regulations come into force. We estimate that 17 companies would be affected by the introduction of a payment mechanism, with the 166 companies that are currently members of the PPRS not being affected. Our proposals would save health services across the UK an estimated £90 million per year.

The second key element of this Bill amends the 2006 Act to strengthen the Government’s powers to set prices of medicines where companies charge unreasonably high prices for unbranded generic medicines. We rely on competition in the market to keep the prices of these drugs down. That generally works well and has, in combination with high levels of generic prescribing, led to significant savings. However, we are aware of some instances where there is no competition to keep prices down, and companies have raised their prices to what looks like an unreasonable and unjustifiable level. As highlighted by the investigation conducted by The Times earlier this year, there are companies that appear to have made it their business model to purchase off-patent medicines for which there are no competitor products. They then exploit a monopoly position to raise prices. We cannot allow this practice to continue unchallenged. My Department has been working closely with the Competition and Markets Authority to alert it to any cases where there may be market abuse and provide evidence to support this, but we also need to tackle it within our framework for controlling the cost of medicines and close the loophole of de-branding medicines. Although the Government’s existing powers allow us to control the price of any health service medicine, they do not allow controls to be placed on unbranded generic medicines where companies are members of the voluntary PPRS scheme. Today, most companies have a mixed portfolio of branded medicines and unbranded generic medicines. For that reason, all the manufacturers of the unbranded generic medicines mentioned in the investigation by The Times are able to use their PPRS membership to avoid government control of their prices.

It should be said that that practice is not widespread, but a handful of companies appear to be exploiting our freedom of pricing for unbranded generic medicines where there is no competition in the market, leaving the NHS with no choice but to purchase the medicine at grossly inflated prices or to transfer patients to other medicines that are not always suitable. Alongside the Government, many in the industry would also like to see this inappropriate behaviour stamped out.

[Norman Lamb (North Norfolk) (LD)]

I very much agree with the point that the Secretary of State has just made. He talked about collaboration with the CMA. Can he give any indication as to whether he expects action to be taken on abuse in the marketplace, given that a small number of companies have behaved appallingly?

[Mr Hunt]

I cannot give the right hon. Gentleman that indication because, as he will know, the CMA operates completely independently, and I therefore do not know what its findings are going to be. Of course, I would support any action that it recommended. I do, however, think that this Bill can give us some security in the House that if the CMA is unable to find evidence in the specific cases it has before it, we will be able to take action as a Government, provided the House is willing to support the Bill.

--- Later in debate ---

[Norman Lamb (North Norfolk) (LD)]

This is an uncontroversial set of measures and I confirm my support for the Bill as it stands. The great strides in medical science over the past decade and beyond are obviously to be celebrated, with cutting-edge new treatments for life-threatening and life-shortening conditions, including a number of rare diseases and cancers, offering many people the hope of improved health, longer life and a quality of life that in the past would not have been possible. As well as the enormous benefits it brings to patients, the life sciences industry makes an incredibly valuable contribution to the UK, and it is only right that we acknowledge that today. However, there is an inevitable cost attached to the triumph of modern medicine, and the challenge is to ensure patient access to new treatments as quickly as possible, while ensuring value for money for the NHS.

The Bill seeks to address some of the shortcomings. It addresses clear abuses of the current system and I think that it will bring greater consistency to the existing arrangements for controlling the cost of medicines new and old. As I have said, I find myself in agreement with the proposals.

It is good that so many companies recognise their responsibility for keeping the branded medicines bill in check by signing up to the pharmaceutical price regulation scheme. Under the scheme, manufacturers pay a rebate to the Department of Health to cover expenditure on branded medicines above agreed limits. It is a responsible approach, helping to ensure that patients can benefit from access to novel drugs in a way that is sustainable for the taxpayer. However, I agree with the Secretary of State on the need to address the current disparity whereby the statutory medicines pricing scheme delivers lower savings than the voluntary scheme. Those differences are expected to widen, which is clearly not in keeping with the spirit of either arrangement, so it makes sense that they should be more closely aligned. As he said, we have to remove the incentive to shift from one scheme to another.

I particularly welcome the proposals to strengthen the authority of the Secretary of State to intervene where unbranded medicines are priced excessively. The NHS and patients benefit immensely from medicines, which were once available only at great public expense, becoming available far more cheaply after the patent expires and generic products come on to the market. We should recognise the great value that the competitive market brings, saving the NHS more than £13 billion every year, according to the British Generic Manufacturers Association, but we also know that the overall cost of generic items is increasing at a faster rate than branded items, and that there have been some outrageous increases, to which other hon. Members have referred, in the price of some individual generic drugs in recent years when there is only a single company producing that drug. It looks like a clear case of profiteering, where the NHS is being ripped off.

Let us be clear what the implications are when a particular company makes an excessive profit from increasing the price of a drug in that way. It means that other NHS patients, particularly those in more marginal areas that do not get the attention that they deserve, lose out. There is less money to spend on, for example, teenagers with mental health problems or learning disabilities. There is a price to be paid for that excessive profiteering. It is utterly unethical behaviour. I hope that the Competition and Markets Authority can find a way to take action against these companies, which appear to have constructed a business model to exploit the loophole.

As hon. Members have said, a number of generic medicines increased in price by more than 2,000% in the last decade. The most horrific example I have come across is a medicine that increased in price from £13.98 in 2005 to £632.96 in 2015, a rise of more than £600 per item dispensed. It is utterly despicable for any private company to think that it can do that. The Government are right to take action to end that outrageous practice.

Generics account for three quarters of prescription items dispensed in the community. In those cases where competition fails to deliver value for money, it is important that there are measures at our disposal to control prices and to tackle abuses that could place intolerable pressure on NHS budgets. It makes little sense that generic medicines can be controlled through the statutory scheme, but that the Government are currently prevented from stepping in when a company’s branded products are regulated through the PPRS. It seems clear that we should remove that anomaly. I should add that, in using these powers to introduce price controls, the Government should of course exercise caution and guard against any unintended consequences that may impact on the viability of smaller companies. I am sure that the Government will be alert to that.

The aims and provisions of the Bill are admirable, but it is only part of a much wider debate about how we can sustain access to groundbreaking new treatments when the NHS is in the middle of the longest financial squeeze in its history. One intervention from a Government Member on the Secretary of State drew attention to the fact that the total bill for drugs is rising at an unsustainable rate. The right hon. Member for Chelmsford (Sir Simon Burns) also raised this question, and we have to address that because the NHS will not be sustainable at the current rate of increase in cost.

It is no secret that the NHS has struggled to adapt to modern medicines, particularly those that carry a large budgetary impact. Both NICE and NHS England have had great difficulty in figuring out which medicines to approve and how those medicines are to be afforded and brought to patients. Recently, NHS England has delayed funding for the new hepatitis C treatment, so I was interested in the points made by the SNP representative, the hon. Member for Central Ayrshire (Dr Whitford).

We also have the ongoing and deeply unsavoury case of the PrEP, or pre-exposure prophylaxis treatment. Not only is NHS England taking its legal challenge to the bitter end to avoid having to pay for the drug, but there have been reports of it pitting patient groups against each other by saying that patients could miss out on vital treatments for cancer or rare diseases for children should PrEP be funded. We do not want to get into comparing the rights and interests of one group of patients against those of another in that way.

Earlier this month, NHS England and NICE launched a consultation on proposals to change the way some drugs are funded when there is a high cost involved. NHS England and clinical commissioning groups are legally required to fund drugs recommended by NICE as being clinically and cost-effective, normally within three months of the guidance being issued, barring unique circumstances. Under the new proposals, if NICE recommends a drug that will bring an estimated cost to the NHS above a certain amount—£20 million is the suggested figure—NHS England can go back to NICE and ask it for longer to roll out the medicine if it is unable to agree a lower price with the manufacturer. Surely that is precisely the opposite of what we ought to be trying to achieve as regards speedier access to new drugs that are coming on stream. Ignoring questions about how that somewhat arbitrary cost threshold was arrived at, there is a concern that this is a creeping step towards the rationing of approved treatments in the NHS. It seems to me to be an admission that the NHS cannot afford to pay even for the drugs that are found to be cost-effective by NICE; similar concerns have been raised by Nicholas Timmins, that highly respected observer who is a senior fellow at the King’s Fund.

The great worry is that opening up the debate on how quickly or slowly approved treatments can be adopted will put us on a slippery slope to a new discussion about whether approved treatments should be adopted at all, and at the very least UK patients will be further disadvantaged—the SNP spokesperson has already made the point that we compare very badly with other countries —and there will be more delays in getting access to new cost-effective treatments.

[Dr Philippa Whitford]

Does the right hon. Gentleman recognise that we are one of a tiny handful of OECD countries that allow that opening price to be set completely by the pharmaceutical industry and to be set as high as it likes?

[Norman Lamb]

I note that point. I suppose my overall point is that given the unsustainable increase in the total drugs bill and given the actions that NHS England and NICE appear now to be taking, it seems that we will be in a more difficult position in getting speedy access to new drugs that can be life-saving. The Government need to reflect on that. The hon. Member for Central Ayrshire made the point in her speech that this Bill tidies up things that have to be tidied up, but there is a much bigger debate about how on earth the NHS can afford vital treatments that in other countries patients are getting access to much sooner.

If we are approaching a situation in which we are unable to cope with new treatments that have been judged by an arm’s length expert body, NICE, to be clinically effective for patients and cost-effective for the NHS, it is yet more evidence that the NHS needs more resources, and I repeat again to the Minister—he will be sick of hearing me say it—that at some point the Government must recognise that they are simply drifting towards a crash with the NHS. We face an existential challenge that this evening’s debate has highlighted and that has to be confronted at some point. I urge the Government again to consider a cross-party approach so that we can ultimately achieve, in discussion with the public, a long-term and sustainable settlement for the NHS and care that recognises both this dramatic increase in the cost of drugs and that all our loved ones want to have access to those drugs in their hour of need.

We should also be mindful of the potential impact of Brexit on the life sciences industry and the additional challenges we face in keeping the NHS medicines bill under control. If trade between the UK and other EU countries becomes subject to customs duties, import VAT and border controls, thereby increasing costs to the life sciences industry, that might in turn drive up the costs of new medicines to the NHS, and impact on access for UK patients to the most innovative new treatments.

Finally, we also need to make sure that evaluation processes and methodologies are fit for purpose. Traditional appraisal methods and notions of cost-effectiveness are unsuitable for many modern medicines, especially for drugs of immense scientific innovation that target just a small number of patients, but the NHS has been slow to respond to that. The Cancer Drugs Fund is a case in point—established as a sticking plaster after a cluster of promising drugs were judged not to be cost-effective. While it is almost certainly the case that many of those treatments came with too high a price to be routinely funded, few would deny that they were being evaluated under outdated processes that could not fully capture their value. Many rare disease treatments suffer from the same problem.

Companies have a duty to ensure that their medicines are fairly priced, but NHS England and NICE also have a duty to make sure that their evaluation processes and decision-making criteria are fit for purpose, so that new medicines are given a fair hearing without some of the excessive delays we have seen in the recent past. We owe it to patients to make sure that happens.

I support this tidying-up measure and, in particular, the ending of the outrageous practice of a number of companies profiteering at the expense of NHS patients, but this debate has also raised a much bigger issue about how we in this country afford groundbreaking treatments that keep our loved ones alive.

Community Pharmacy in 2016-17 and Beyond

Norman Lamb Excerpts

1st reading: House of Commons
Thursday 20th October 2016 Commons Chamber

[David Mowat]

The access scheme to which I referred will apply to rural and urban pharmacies. Indeed, there is more urban than rural in it, but it will protect rural pharmacies in the way my right hon. Friend mentions.

[Norman Lamb (North Norfolk) (LD)]

There is no escaping the fact that this amounts to a significant cut in prevention services, which is what always happens when the finances of the NHS are under pressure. I absolutely accept the need for reform of the financial incentives involved, to ensure that we get the best outcomes from the money being spent, but surely we should be investing more in prevention in order to ensure that the NHS is sustainable.

[David Mowat]

The quality system that I have mentioned is about potentially investing more in prevention and linking the best pharmacies—the high quality pharmacies—more closely to local authorities, public health schemes and all that goes with that. I make the point again that there is a requirement for efficiency savings, but we do not believe that they will affect access overall. We do not believe that this will affect the public’s ability to use pharmacies as they do now. This will be part of modernising and digitising the service and providing resources for other parts of the NHS that need them very much.

Tobacco Control Plan

Norman Lamb Excerpts

Thursday 13th October 2016 Westminster Hall

[Alex Cunningham (Stockton North) (Lab)]

I beg to move,

That this House has considered the tobacco control plan.

It is a pleasure to serve under you chairmanship, Mr Brady. I am grateful to the Backbench Business Committee for granting us the opportunity to debate this issue in the depth and detail required. The subject has an impact on all of us, and it is right that time is allocated for a meaningful and thorough debate. I am also grateful to my colleagues from across the House who helped to secure the debate and who will, I am sure, make some incisive and insightful contributions.

I am pleased to have been part of the team that has consistently advocated tobacco control, and I am proud of the achievements we have made. The great thing about those achievements is that they have been built on strong cross-party commitment in both Chambers, with the devoted support and drive of external organisations and charities across the country that are determined to keep the harm caused by tobacco very much in the minds of the public and, of course, Ministers. Those organisations have succeeded.

A recent Action on Smoking and Health survey of more than 12,000 people found overwhelming public support for Government action to limit smoking and strong support for the Government to go further and do more. That is no surprise, really, as tobacco control is an area where Government action is highly effective.

Let me start with a parochial statistic. Back in Stockton, 250 miles up the road, smoking prevalence was estimated at 27.5%—more than one in four people—as recently as a decade ago. However, by last year various policies and interventions had seen that figure fall to 18.4%, which is a decrease of about a third. That means that some 14,000 fewer adults in Stockton now smoke than in 2005. I, for one, am very proud of that achievement.

I speak not only as a member of the all-party parliamentary group on smoking and health, the secretariat for which is provided by ASH, but as an MP who, as a humble Back Bencher, successfully pressed for the legal changes around smoking in cars when young children are present, with the support of groups including the British Lung Foundation, Cancer Research UK and the British Heart Foundation. That is on top of the principled and unwavering support I have received from north-east organisation Fresh, which covers my patch in Stockton North and whose joint conference on the harms of tobacco and alcohol I was pleased to address just a fortnight ago.

The dedication to improving public health and promoting tobacco control runs deep not only in my own psyche but in that of colleagues across the House. Back in 1998, the Labour Government introduced the country’s first comprehensive tobacco control strategy. Legislation has moved on since then to prohibit tobacco advertising, smoking in public places and smoking in cars carrying children, and to implement controls on point-of-sale displays. I welcomed all those measures, but I am only too aware that there is much more to be done.

The most recent measure was the introduction of standardised tobacco packaging, which I repeatedly called for and supported. Although the original form of the Children and Families Act 2014 contained no measures at all to protect children from the dangers of smoking or to avert uptake, the amendment on standardised packaging tabled in the House of Lords by Baronesses Finlay and Tyler and Lords Faulkner and McColl was swiftly taken up by the Government and brought to fruition.

In the spirit of debating the issues and the evidence base rather than the politics of any decision, I thank the previous public health Minister and current Financial Secretary to the Treasury, the hon. Member for Battersea (Jane Ellison), for her consistent support for tobacco control and, in particular, standardised packaging. That was duly recognised by her receipt of the prestigious World Health Organisation director general’s special award to mark World No Tobacco Day earlier this year.

A great deal was achieved under the previous plan, “Healthy Lives, Healthy People: A Tobacco Control Plan for England”. Progressive tobacco control legislation was introduced, and the three key ambitions of the plan have been achieved. Smoking rates among adults and children have fallen below the target levels, and rates of smoking during pregnancy reached the 11% target earlier this year. That illustrates perfectly why Britain is a world leader in tobacco control, with the UK coming top in a European survey measuring the implementation of key tobacco control policies and passing legislation that goes further than the requirements set out in European Union directives—perhaps that is one area in which we can expect no negative impact from Brexit. Yet there is still much to be done.

Smoking is responsible for approximately 78,000 preventable and premature deaths each year in England alone, and nearly 100,000 across the UK. In the north-east, the number of deaths from smoking-related diseases is some 30% higher than the English average. Despite the fact that we have hit the national targets on smoking prevalence laid out in the previous plan, stark variations in prevalence persist regionally and among different groups. A national tobacco control strategy should therefore be introduced without delay.

In her Downing Street speech, the new Prime Minister committed her Government to

“fighting against the burning injustice that if you’re born poor you will die on average nine years earlier than others”.

Half of that difference in life expectancy is solely due to higher rates of smoking among the least affluent members of our society, with smoking rates among those with multiple complex needs reaching as high as 80%. I am clear that we should all share that commitment.

In Stockton, just under 30,000 people smoke—that is just over 18% of the population. However, it has been estimated that 539 children between the ages of 11 and 15 start smoking in Stockton-on-Tees every year, with 964 people dying from smoking-attributable causes from 2012 to 2014. Shockingly, that is the equivalent of almost 5,000 years of life lost due to smoking. That death and disease is disproportionately borne by the poorest people in my area.

Although smoking rates among the adult population fell throughout the life of the previous tobacco control plan, health inequalities have remained stubbornly high. In 2013, for instance, smoking prevalence among people in the routine and manual socioeconomic group was more than twice that among the professional managerial group—28.6% compared with 12.9%. The picture is even worse for those who are unemployed, with smoking rates of approximately 35%. People earning under £10,000 a year are more than twice as likely to smoke as those earning more than £40,000 a year. The higher rates of smoking place a significant financial burden on poorer members of society. If the costs of smoking were returned to households, 1.1 million people, including more than 300,000 children, would be lifted out of poverty.

In Stockton-on-Tees, when tobacco expenditure is taken into account, almost 6,000 smokers fall below the poverty line, including more than 1,300 dependent children. Those innocent children not only suffer from the financial burden of their parents’ smoking but are more likely to be exposed to second-hand smoke and to try smoking themselves. We all know that those who grow up in a household where parents or siblings smoke are far more likely to become smokers themselves.

Those children may experience considerable peer pressure to start smoking, and tobacco is often more accessible to them in the community and at home, thus creating a cycle of inequality and leading to the life expectancy gap noted by the Prime Minister. Perhaps worse still is that when poorer smokers attempt to quit smoking, they are less likely to succeed than their more affluent peers.

To tackle inequalities, support to stop smoking needs to be specifically tailored to meet the needs of those in lower socioeconomic groups. Although the ambitions in the previous plan have been met and smoking rates continue to decline, they remain stubbornly high in disadvantaged sections of society. Further action is needed from the Government and the public sector to reduce smoking rates and associated health inequalities, and the new strategy is necessary to drive that action forward.

With that in mind, and given that the policy development work for a new tobacco control plan was in place for publication this summer, I would welcome the Minister telling us when the new plan will be published. I say to her that there is a standard to live up to, because the last time there was a debate about the plan in this room, the then Minister confirmed the timing of its publication. I hope we will hear about that in depth today.

Perhaps the Minister will also oblige the British Lung Foundation and outline the Government’s plans to prioritise lung health as an area for health improvement. Will she tell the House whether an assessment of respiratory health could be included in the NHS health check?

[Norman Lamb (North Norfolk) (LD)]

I am grateful to the hon. Gentleman for giving way, and I very much agree with what he is saying. He has talked a lot about inequality, which of course spreads beyond this country. I understand that some 80% of smoking deaths, which will rise to 8 million by 2030, are in lower and middle-income countries. Does he share my desire to see the Government publish the plan before the meeting in India in November? We could then see what the special fund for developing countries will be used for, because we need to have an impact there, too.

[Alex Cunningham]

I agree. With the huge proportion of deaths in lower-income countries, which are suffering even more than we are in this country, it is imperative that the report is published so that we can show a lead. We are a leading country, if not the leading country, on smoking control, and we must continue to demonstrate that.

As colleagues will be aware, stop smoking services are one of the most effective healthcare interventions. Smokers are four times more likely to quit successfully with the combination of behavioural support and medication provided by those local services. Significantly, smokers from routine and manual socioeconomic groups are more likely to access the support of stop smoking services, which have real potential and are an effective way of beginning to address health inequalities. In 2014-15, for example, more than twice as many smokers from routine and manual groups set a quit date with a stop smoking service compared with those in professional and managerial occupations. Such services are not only effective in supporting efforts to quit but can prevent the disability and distress caused by smoking-related diseases without the side effects of many of the drugs used to treat such diseases. Indeed, the National Institute for Health and Care Excellence considers smoking cessation treatment to be among the most cost-effective healthcare interventions.

Smoking cessation treatment is also cost-effective for those who already have smoke-related diseases. Take chronic obstructive pulmonary disease, for instance. Some 900,000 people in England have been diagnosed with smoking-related COPD, out of about 3 million sufferers. Some 25,000 people a year die from the disease, and the NHS spent £720 million on treatments in 2010-11. The British Lung Foundation estimates that in my constituency, people are as much as 60% more likely to be admitted to hospital with COPD than the UK average. We also discovered recently that the rate of lung disease in my constituency is the second worst in the country.

Yet COPD is a disease that is almost entirely preventable. Smoke is the cause of more than three quarters of COPD cases, and in this country exposure to such smoke is primarily through smoking. Although it is clearly better to prevent COPD through the provision of smoking cessation treatment to help smokers quit before the disease develops, that treatment can help improve quality of life even after the onset of COPD and is highly cost-effective compared with other treatments. Indeed, it is the only treatment that can prevent the disease from progressing in smokers. The cost of smoking cessation treatment for people with COPD is estimated to be £2,000 per quality-adjusted life year, whereas the cost of drug treatment for those with the disease ranges from £5,000 per QALY at the bottom end of the scale to £187,000 per QALY for triple therapy.

I am mindful that this is a co-operative debate with cross-party support, but I believe it is fair to highlight the impact of some of the Government’s economic measures on smoking cessation programmes. In 2014-15, despite all the evidence of their cost-effectiveness, approximately 40% of local authorities cut the budgets of their stop smoking services, with half of all services being reconfigured or recommissioned. It is not just local authority cuts that are happening; we are now hearing that clinical commissioning groups are also cutting funding for prescriptions to stop smoking medications and refusing to fund smoking cessation services.

Local authorities faced with huge cuts to their budgets are reducing investment not only in stop smoking services but in other areas essential to effective tobacco control. Trading standards staff, who are crucial to tackling illicit tobacco and under-age sales, are increasingly under threat. During the past six years, the total national spend on trading standards has fallen from £213 million in 2010 to £124 million today. Teams have been cut to the bone, with a 12% drop in staff working in trading standards since 2014, on top of the 45% drop over the previous five years identified by an earlier survey.

The importance of trading standards, working in partnership to deliver concerted multi-agency enforcement activity, is shown in my region, the north-east. After setting up a regional illicit tobacco partnership, the region has seen a significantly greater fall in the illicit tobacco trade than has been seen at national level, to the benefit of both public health and Government revenues. Between 2009 and 2015 the illicit market declined by more than a third in the north-east, from 15% to 9%, whereas the decline at national level was less than a fifth, from 12% to 10%.

Without sustained funding, such services are simply unable to continue to operate effectively. The new tobacco control plan therefore needs to prioritise cutting health inequalities rather than budgets, and in so doing must protect public health funding for tobacco control. I hope the Minister will confirm today that the Government will take steps to sustain protected funding for tobacco control, and will outline what those steps will look like.

I would similarly welcome hearing the Minister commit to bringing mass media spending in line with best practice evidence. Research has shown mass media campaigns to be highly effective in promoting quit attempts and discouraging uptake. In the UK, however, we are currently falling far below best practice spending on such campaigns. When funding was cut back in 2010 there was a noticeably negative impact on quitting, with a whopping 98% decrease in requests for quit support packs, a fall of almost two thirds in quit-line calls and more than a third fewer website hits. That should hardly come as a surprise, with year-on-year cuts seeing only £5.3 million spent on mass media in 2015, which is less than a quarter of the amount spent in 2009. Spending has actually declined further this year to £4 million. To make matters worse, it is not even clear how much, if any, of that budget is reserved for televised mass media campaigns.

This year’s annual Stoptober campaign, for instance, is being run without any televised advertising. Yet the evidence confirms that it is precisely such mass media campaigns that are essential to motivate quitting and to inform smokers of the useful resources provided by Public Health England to help smokers quit. Those campaigns, which discourage smoking and encourage quitting, are most effective when they are sustained and sufficient, with the best results being achieved when people are exposed to televised anti-smoking adverts around four times a month.

Again, I draw attention to my own patch and the “Quit 16” mass media campaign co-ordinated by Fresh and Smokefree Yorkshire and Humber, which focused on the damage smoking does to health. Some 16% of those exposed to the campaign, or roughly 53,300 people, cut down on their smoking. A further 8.4% made a quit attempt, and 4% switched to electronic cigarettes. That shows the clear impact that mass media campaigns have on triggering quit attempts and changes in behaviour, and the Government need to take such evidence seriously and commit to investing in mass marketing campaigns without delay.

Members will be aware that the decline in smoking prevalence in the UK since the first comprehensive strategy was published in 1998 has been comparable to that in Canada and Australia, both of which have consistently addressed the harms caused by smoking through comprehensive and sustained tobacco control strategies. Smoking prevalence has declined rapidly among adults and children in England since the Government first implemented such strategies from 1998. The latest figures show that adult smoking prevalence in England has declined by more than a third, falling from 27% in 1998 to 16.9% last year. The proportion of 15-year-olds in England who are regular smokers fell by two thirds between 1998 and 2014, hitting 8%, and the proportion of 11 to 15-year-olds who have ever smoked fell from 47% to 18% over the same period. Those are the lowest figures ever recorded for both adults and children.

None the less, smoking remains the leading cause of preventable premature death and the major reason for differences in life expectancy between the richest and poorest in society. Experience elsewhere shows what can happen if we do not review and renew our tobacco control strategy and ensure that it is properly funded. While the UK has seen a significant decline in smoking because of its comprehensive approach, the prevalence of smoking in France and Germany, which have not had any such strategies in place, has barely shifted over the last 20 years. We cannot rest on our laurels and assume that the long-term declines we have achieved will continue unabated if we do not take decisive action to review and renew our strategy.

On 14 September, Lord Prior committed the Government to publishing a new plan, with renewed ambitions to reduce smoking prevalence further and new ambitions on health inequalities and mental health. However, he would not commit to a publication date, so I repeat my appeal to the Minister to reassure Members across the House by filling that gap today. There is no clear reason to delay publication of a new plan further. If the Prime Minister’s ambition to reduce health inequalities is to be achieved, Ministers need a comprehensive strategy on tobacco control sooner rather than later.

--- Later in debate ---

[Norman Lamb (North Norfolk) (LD)]

It is a pleasure to serve under your chairmanship, Mr Brady, and to follow the hon. Member for Harrow East (Bob Blackman). I find myself in agreement with everything he said. Anyone who has come here hoping to see violent disagreement and robust debate will be disappointed, because we all agree about the importance of this issue.

The hon. Gentleman talked clearly about the nature of this lethal product, which, as we have heard, kills 96,000 people a year across the UK. He also touched on the issue of the developing world. It is anticipated that 8 million people across our world will die from smoking in 2030, and that 80% of them will be in low or middle-income countries that do not have strategies to tackle the problem. Companies based in this country are selling this lethal product to the developing world and killing so many people. We need to be clear that that is shameful.

Many hon. Members, including the hon. Member for Totnes (Dr Wollaston) and the hon. Member for Stockton North (Alex Cunningham)—I congratulate him on all the work he has done and on leading this debate—have talked about the inequalities that are associated with smoking tobacco, including wealth and income inequalities. Smoking hits people from low-income communities much harder than others. As Members have said, smoking is about half of the reason for the difference in life expectancy between the richest and the poorest in our country.

I want to talk about another inequality, which the hon. Member for Harrow East touched on at the end of his contribution: the impact on people with mental ill health. A substantial part of the reason why such people, particularly those with severe and enduring mental ill health, die 15 to 20 years earlier than others is higher smoking rates. Here’s the thing: we have been very successful in this country—I will come back to this in a moment—at reducing the smoking rate. Public health strategies have worked effectively, although we all recognise that there is much further to go. But as the smoking rate has come down in the population as a whole, it has remained stubbornly high among those with severe and enduring mental ill health; there has been hardly any shift at all. That has been a failure of public health strategies.

Back in 2013, when the smoking rate across the population was 21%, it was 40% among those with severe and enduring mental ill health, 60% among those with psychosis, and 70% among people in in-patient care. We can start to see why those people end up dying so much earlier than everyone else. That amounts to a neglect of those people’s need for support in combating this highly addictive product, and it makes me absolutely driven—as is everyone else in the Chamber—to do more to combat the problem.

Let me come back to the successes of smoking cessation strategies. I join other hon. Members in congratulating the hon. Member for Battersea (Jane Ellison) on her work. The hon. Member for Harrow East was right; there are Government Members who take a different view. I remember hearing the hon. Member for Battersea speaking and wanting to tell her to watch her back, because there were quite a few Members behind her who took a different view. She was brave in standing her ground, particularly in pursuing the plain packaging policy. The right hon. Member for Rother Valley (Kevin Barron) has a plain packet in his pocket. The previous Government were in my view a coalition Government, not a Conservative-led Government; the Liberal Democrats played our part in important strategies such as plain packaging and ending smoking in cars with children on board, which will have a big impact on saving people’s lives.

It is imperative that the new strategy is published and becomes operational. Given the leadership role that we have played for so many years, it is important that we go to the meeting in India in November and demonstrate our continued leadership. If there is any way for the strategy to be published before that meeting, and for it to include a focus on how we will use the fund that has been established for combating smoking in developing countries, I urge the Minister to do everything possible to ensure that that happens.

Let me speak a little more about what the tobacco control plan needs to include. I come back to what I said about mental health, which the plan needs to address directly. I do not know whether the Minister has seen the iterations of the plan, which we hope will be published soon, but I hope very much that it will address directly the failure of public health strategies to reduce smoking among people with mental ill health. The plan needs to focus on the recommendations of the report “The Stolen Years”, which was published by ASH and produced in collaboration with the Royal College of Psychiatrists, and its ambitious targets for reducing smoking among people with mental ill health. We can no longer fail to confront the failure of past strategies in that respect. Interestingly, that report highlights the therapeutic benefits of stopping smoking for people with mental ill health, not only for their physical health but for their mental health. Ironically, many people with mental ill health smoke because they see it as an escape from the pain that they are suffering and a way of coping with stress, yet smoking increases stress and the risk of aggression, particularly in in-patient services.

[Kevin Barron]

I went to the launch of that report. Some 70% of people who are discharged from mental health secure units smoke, yet we have in our midst a product—e-cigarettes—that could have been designed to be put into such institutions, some of which are now putting e-cigarettes on their shopping lists. That would allow people to satisfy their addiction without creating secondary smoke and the many ailments that occur when people smoke. Does the right hon. Gentleman agree that we need more leadership to ensure that e-cigarettes can be used in institutions where, for control reasons, it is difficult to keep the customer satisfied, as it were?

[Norman Lamb]

I completely agree. If we want to focus effort where it is most needed and where smoking rates are highest, we should focus on those very mental health institutions. As well as making vaping available for people who need help to give up smoking, we need to do much more to focus on training staff in such institutions so that they know the importance of smoking cessation being one of the objectives in the care of individuals there, because of its potential therapeutic benefit.

I should also mention the move towards smoke-free in-patient settings, a strategy that I supported as Minister and that I am pleased is continuing. Guidance was published by Public Health England and NHS England in June 2015, and that strategy is having a beneficial effect on the environment in in-patient settings by reducing aggression and stress and improving physical and mental health. I encourage the Government to keep pursuing that objective.

On electronic cigarettes and vaping, although I was a committed remainer in the EU referendum debate, the tobacco products directive is flawed, because it takes an inappropriately tough approach to electronic cigarettes. I therefore hope that the Government will review that directive regularly. One of the potential benefits of leaving the EU—there are not many, in my view—is that we will gain the ability to differentiate more between the effective regulation on tobacco in that directive and the regulation on electronic cigarettes, and do much more to recognise the evidence that already exists, as the right hon. Gentleman has made clear, on the benefits of electronic cigarettes.

I will end by saying something about public health funding. The hon. Member for Totnes made the point clearly, and I totally share her view. The Health Committee has pointed out that the £8 billion or £10 billion that we keep being told will be given to the NHS by 2020 is actually nearer £4.5 billion. Extra money is being found for front-line NHS services partly by cutting other parts of the Department of Health budget, including, distressingly, public health and health education. As she said, that is completely counterproductive. When NHS finances get tight, crisis management takes over. The hon. Member for Stockton North made the point that CCGs are focusing on propping up established traditional services—the repair services, as it were—and in so doing, tragically, are cutting the prevention services that prevent people from ending up needing care in the first place. That is so counterproductive. A new settlement for the NHS and the care system, which I keep calling for, must recognise the imperative to invest more in prevention and public health, particularly given that there is so much evidence that that has a beneficial effect.

--- Later in debate ---

[Norman Lamb]

On the adequacy of public health budgets, does the Minister think it is rational in any way to increase in real terms the budget for the NHS while reducing in real terms the budget for public health?

[Nicola Blackwood]

Prevention is a core part of the NHS five year forward view and should be embedded in NHS funding, public health funding and social care funding, as the right hon. Gentleman has stated. We are looking for the STPs to show a joined-up plan for how prevention, acute delivery services and social care will work together. PHE can and does advise and support local councils to tailor their services effectively, but we need to see how we can improve that. The local tobacco control profiles are one way in which we are doing that, but we must ensure that we see some of that work implemented.

At national level, to help drive a reduction in variation, the Government are committed to publishing the new tobacco control plan that all Members have mentioned, which has tackling inequalities at its heart. The plan will build on our success so far and will include renewed national ambitions. We have to maintain the proactive, comprehensive and non-partisan approach we have seen so far. The UK is recognised as a world leader in tobacco control strategy, and we intend to maintain that. However, I am afraid that on this occasion I will not be able to match my predecessor by announcing the date of publication. [Hon. Members: “Oh!”] I know; I feel inadequate.

My hon. Friend the Member for Harrow East is right in identifying my desire to ensure that the plan is evidence-led. It is reasonable for a new Government to want to check that the plan offers the best possible strategy, based on evidence. On something as important as a tobacco control plan, which is a golden moment, we have to ensure that we do not publish the plan until we get it right. It has been valuable to have the opportunity to listen to and engage with this debate, so that I can hear from colleagues as expert and engaged as those present before going forward. I assure all Members that the Government see the issue as a matter of urgency and are pressing forward with the plan as quickly as possible. I will certainly take away the suggestion from the hon. Member for Stockton North about incorporating respiratory health monitoring into the NHS health check.

I would like to go through a few of the points that we have discussed before I finish. As I have highlighted, it is right to turn our focus to population groups in which smoking prevalence remains higher than elsewhere. In particular, we must turn our attention to reducing health inequalities in populations who already suffer from poorer health and social outcomes, such as those in routine or manual occupations or those who suffer from mental health conditions.

As my hon. Friend the Member for Totnes said, improving maternity outcomes and giving children the best start in life is an important priority for this Government, and supporting pregnant women to quit smoking will be an important factor in working towards that. We all know that smoking during pregnancy increases the risk of stillbirth, as the shadow Minister said, and of problems for a child after birth. We also know that babies born to mothers who smoke are more likely to be born underdeveloped and in poor health. Tackling that was a priority under the previous tobacco control plan, during the period of which smoking prevalence among that group fell by three percentage points, but more can be done to reduce it further and, most importantly, to tackle the variation I mentioned. We will look at that.

Alongside limiting babies’ exposure to smoke during and after pregnancy, we must continue to work to end the cycle of children taking up smoking in the first place. As the percentage of 15-year-olds who regularly smoke has fallen to 8% and continues to fall, we must press our advantage and work towards our first smokeless generation. That would be something that we could genuinely be proud of. Restricting access to tobacco remains key, and we will want to maintain the enforcement of measures mentioned today, such as age of sale laws. Evidence shows that children who have a parent who smokes are two to three times more likely to be smokers themselves. Continuing to support adults to quit is therefore vital to ending the cycle of children taking up smoking and must remain a key part of tobacco control in the future.

In order to achieve our ambitions for the population groups I have mentioned, and to reduce smoking prevalence across all populations to even lower rates, we have to continue to draw on the things that we know work. This is an area in which we have a strong evidence base, and that work will include continuing a programme of evidence-based marketing campaigns such as Stoptober and monitoring the evidence base for e-cigarettes.

Finally, the right hon. Member for North Norfolk is right to say that tobacco use is a global issue and an international priority. Our new tobacco control plan will need to reflect that. As a world leader on tobacco control, the UK will continue to work closely with others to reduce the burden that smoking places on individuals, families and economies across the globe. As he said, we are investing official development assistance funds over five years to strengthen the implementation of the WHO’s framework convention on tobacco control. The project will be delivered by the WHO, and through it, we will share the UK’s experience in tobacco control to support low and middle-income countries to put effective measures in place to stop people using tobacco. That will happen through capacity sharing. We will carefully monitor the progress of that initiative to ensure that it delivers results, using very effective evaluation measures. I am happy to have further discussions about that with the right hon. Gentleman, if he would find that helpful.

We can be proud of the progress that successive Governments have made on helping people to quit smoking, preventing them from starting in the first place and creating an environment that de-normalises smoking. With prevalence rates at an all-time low, there is no question that good work has been done, but as the issues raised in this debate clearly show, there is more work to be done. The Government are committed to doing that work as a matter of urgency. I will take away the comments made today, which are incredibly helpful to me as a new Minister, and I will ensure that as we finalise the new tobacco control plan—

Oral Answers to Questions

Norman Lamb Excerpts

Tuesday 11th October 2016 Commons Chamber

[Mr Dunne]

The hon. Gentleman has a consistent track record in opposing PFI, even when the vast majority of the schemes were put under contract by the Government of which he was a member—so I will not take any lectures from him about how to deal with PFI. We will continue to use the new stricter terms as and when appropriate.

[Norman Lamb (North Norfolk) (LD)]

The National Audit Office concluded that the PFI contract for the Norfolk and Norwich hospital was a bad deal for the taxpayer and for the NHS, yet last year Octagon Healthcare made a record profit as the Norfolk and Norwich’s finances sank ever further into the red. Will the Minister consider making a formal approach to Octagon Healthcare to ask it to forgo part of its profit to help confront the enormous financial black hole that the trust faces?

[Mr Dunne]

We have provided access for seven of the worst affected trusts with obligations under PFI to a support fund of some £1.5 billion to help them with those obligations. I am not sure whether Norfolk is one of them; I suspect that it is not. I would be happy to talk to the right hon. Gentleman about this, but rather than raising his hopes inappropriately I have to say to him that many of the schemes are too costly to divert resource to pay them off completely.

NHS Sustainability and Transformation Plans

Norman Lamb Excerpts

Wednesday 14th September 2016 Commons Chamber

[Ms Abbott]

That is the reason for the secrecy thus far. The Government know that if the public understood what STPs meant, there would be an outcry.

[Norman Lamb (North Norfolk) (LD)]

Does the hon. Lady agree that unless the local community are fully engaged in the process of considering how the health and care system needs to change their area, the process is destined to fail and simply will not work?

[Ms Abbott]

I am grateful to the right hon. Gentleman. For nearly the whole time I have been in Parliament, there have been attempts to reconfigure hospitals and close A&Es and make other changes in London. We have found that when the local community does not take ownership of the plans, it is impossible to take them forward. That secrecy runs counter to making the reorganisations we might have to make.

--- Later in debate ---

[Mr Dunne]

I am delighted to accept that invitation from my neighbour and friend, not least because many of my constituents look to Hereford County hospital for their acute care, but also because it is one of the hospital trusts that are in special measures, which is my specific responsibility. I look forward to seeing my hon. Friend there, perhaps even during the coming recess.

[Norman Lamb]

I wish the Minister all the best in his new role. Does he share my concern about the evidence from around the country that in many areas mental health is peripheral to the STP process? Will he ensure that no STP plan will be accepted unless mental health is central to it?

[Mr Dunne]

I am grateful for that intervention from the right hon. Gentleman, who has taken such a personal interest in this subject. I can confirm that mental health is one of the issues that will be addressed in each of the plans that will be taken forward. I hope that reassurance helps.

--- Later in debate ---

[Dr Whitford]

I totally agree with the hon. Gentleman. I was about to come on to that. However, it is not just the funding, but the entire model. The tariff model that we have at the moment rewards hospitals for doing more minor things, and punishes them for doing more acute things. Taking on more A&E cases and more complex cases, working harder and doing more make their deficits grow. Our problem is that we have all sorts of perverse incentives in the system that mean that organisations will still be looking out for their budgets and their survival instead of working together.

In Scotland, we got rid of hospital trusts and primary care trusts, and, since 2014, we have had integrated joint boards. Those boards were handed joint funding that came from health and the local authority, which meant that the whole business of “your purse or my purse” disappeared. They were then able to start to look at the patient’s journey and the best way to make the pathway smooth. That is what we want to see.

Having a shared vision of where we are trying to go to is crucial. That means that stakeholders—both the people who work in the NHS and the people who use it—need to believe in where we are trying to get to. Public conversations and public involvement are the way forward. We should not be consulting on something that has already been signed off, but involving people in what they would like the plans to be, as that would make those plans much stronger.

We need to make deep-seated changes to the system, as opposed to only talking about the money for the deficits. This is something that the Health Committee has been talking about for ages. The phrase “sustainability” has become shorthand for paying off the deficit. Of the £2.1 billion earmarked for sustainability and transformation, £1.8 billion is for deficits, which leaves only £300 million to change an entire system. I know that we talk about money a lot in here, and of course it is important, but we have far bigger sustainability issues than the £2.5 billion deficit in the NHS. We have an ageing population, and those people are carrying more and more chronic illnesses, which means that we have more demand, more complexity and more complications. That is one of the things that is pushing the NHS to fall over. On the other side of that, we have a shortage in our workforce; we do not have enough nurses or doctors, and that includes specialists, consultants, A&E and particularly general practitioners. Although the advice has been very much that finances were third, and prevention and quality of care were meant to come first and second in delivering the five year forward view, finances seem to be trumping everything else.

It is absolutely correct that health is no longer buildings; there are lots of methods of health that are bringing care closer to patients, and also some things that are taking patients further away from their homes. We have hyper-acute stroke units, and we have urgent cardiac units, where they will get an angiogram and an angioplasty that will prevent heart failure in the future. However, we cannot start this process there; we cannot shut hospitals and units to free up money to do better things. We have to actually go for the transformation and do the better things first. We have to design the service around the pathways we need—that wrap-around care for patients—and then work backwards. If more health and treatment is coming closer to the patient, at some point they will say, “Actually, I don’t go to the hospital very often. I want the hospital to have everything it needs when I need it.” Then we can look at the estate to see whether we have the right size of units and the right type of units in the right place. What concerns me is that the process we have seems to be the other way around—we are starting with hospitals, which is often a very expensive thing to do, and hoping it will deliver everything else.

[Norman Lamb]

rose—

[Dr Whitford]

I give way to Norman.

[Norman Lamb]

I am grateful to the hon. Lady for giving way, even if she used my first name. Does she share my concern that, out of the original sum allocated for this sustainability and transformation process, the vast bulk appears to be going, in effect, to propping up acute trusts that face substantial deficits, and that little is available for transformation?

[Dr Whitford]

As I said, the proposals leave only £300 million. We cannot transform a system on the scale that is being considered with £300 million.

As I said, the guidance talks about prevention. We need to be tackling health inequalities. We need to be focusing on health and wellbeing—and by that I do mean physical and mental wellbeing. We need to be strengthening public health—something else that has been cut. We need to be looking at the quality of health and care, and that means right across into social care. We must fund social care, because it can make a difference to things like delayed discharges. We are not even three years into the integration in Scotland—we are only two and a half years into it—but delayed discharges have dropped 9%. Yet, the last time the Secretary of State was in the Health Committee, they had gone up 32% in NHS England. So literally just moving things around and allowing one part of the system to fail will mean that the entire system fails.

--- Later in debate ---

[Norman Lamb (North Norfolk) (LD)]

I want to start by saying that I very much agree with the point made by the hon. Member for Central Ayrshire (Dr Whitford) that this ought to present a real opportunity. It has brought people together, and discussions have started across organisations that in the past have not talked to each other nearly enough—both across the health and social care divide, and also bringing in people from outside the health service and social care system—but I fear that the opportunity will be fatally undermined for three central reasons.

First, there is the point that I made in my challenge to the Minister, on mental health: unless every STP addresses the burden of mental ill health in every community centrally as part of its plan, it will fail. There is no doubt about that. I noted the Minister’s attempt to reassure me, but the parliamentary answer I received recently did not reassure me, because it appears that it is not going to be a requirement that every plan must centrally address this problem. I understand that the more developed plans will do so, but if this is not done, it will absolutely fail. We are dealing often with some of the people who are failed most by the system, and who use A&E departments more than any other people, yet my fear is this will be a massive missed opportunity in that regard.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

I thank the right hon. Gentleman for giving way, because I want to make the point again—I will say it very clearly—that if an STP does not come forward with very clear plans as to how the mental health and dementia programmes are going to move forward quickly, it will not go ahead. That cannot be clearer.

[Norman Lamb]

I am grateful to the Minister for that, and I hope that that message goes out across the country, because Andy Bell from the Centre for Mental Health today has again raised concern about the process in many parts of the country.

The second issue that causes me very real concern is the financial backdrop and the ability to deliver on the plans given the finances that are available. We have already heard that the bulk of the money that is available is going into clearing the deficits of providers, rather than into the transformation that is so necessary in order, as the hon. Member for Spelthorne (Kwasi Kwarteng) made clear, to spend money more efficiently and effectively in delivering care for our communities.

Chris Ham, chief executive of the King’s Fund and a well-respected commentator, says that its assessment of the draft plans

“shows that, in the absence of eye-watering efficiency improvements, there will be a financial gap running into hundreds of millions of pounds by 2020/21 in most of the footprints”—

not across the country, but in most footprints. This is completely unachievable, and he questions the deliverability of plans which include the closure of cottage hospitals in many areas—the very things that can keep people out of acute hospitals, yet we are planning in many areas to close them down. This seems to me to make no sense at all.

There is a related concern about governance. Currently in the NHS we regulate organisations, not systems, so within an STP footprint every organisation still has to focus on its own financial survival, rather than looking at the best approach for the entire health and care system in that locality. I fear that that in itself will be a central flaw.

Finally, there is the question of openness and transparency. I note the point that there will be a consultation process, but let me just tell the Government that if they really think that a formal consultation process after full draft plans have been produced in a secret process will in any way convince the public that they are being properly involved, it will fail. It is inevitable that it will fail. People are so suspicious of consultation processes that they simply do not believe that they are being properly engaged in them.

The hon. Member for Spelthorne made a good point: people are often prepared to go on a journey. They are prepared to listen to potentially radical changes and potentially to use money more effectively, but the only way they will do that is if they are involved from the start—involved in shaping the proposals, rather than responding to something that has been fixed behind closed doors. The hon. Member for Bedford (Richard Fuller) knows full well how the public react when they are presented with what looks like a fait accompli. If the public are not involved in the development of plans to close cottage hospitals, to slim down acute hospitals and to merge hospitals around the country, we should be in no doubt that those plans will be rejected. The Government will be facing a political disaster if they plough on in this way. They must, for example, open up and involve the non-executive directors, who have been told that they cannot even be part of the discussions. That is ridiculous. For goodness’ sake, if we are to take people with us, we have to take them on a journey, engage with them and involve them in the plans.

[Matthew Pennycook (Greenwich and Woolwich) (Lab)]

rose—

[Norman Lamb]

I will give way very briefly to the hon. Gentleman—[Interruption.] I am being given a clear signal by Mr Deputy Speaker that I should not—

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. You have only 30 seconds to go.

[Norman Lamb]

I take your point, Mr Deputy Speaker, and I am sorry for my ill discipline.

I will conclude by saying that this is the right approach but it will be undermined because of the rushed process which does not involve the public, because it does not take people with it on the journey and because there is not enough money to deliver the transformation that is required.

[Several hon. Members rose—]