Access to Medicinal Cannabis

Baroness Blackwood of North Oxford Excerpts

Tuesday 9th April 2019 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, with permission, I shall now repeat the response to an Urgent Question on medicinal cannabis originally made by the Secretary of State for Health and Social Care:

“First, Mr Speaker, my sympathies go out to the patients and their families who are desperately seeking to alleviate their symptoms with medicinal cannabis. We are working hard to make the right approach. The law was changed on 1 November last year and it is now legal for doctors on the specialist register of the General Medical Council to prescribe cannabis-based products for medicinal use in the United Kingdom.

Whether to prescribe must remain a clinical decision to be made with patients and their families, taking into account the best available international clinical evidence and the circumstances of each individual patient. Indeed, there have already been prescriptions written for the products that the family attempted to bring into the country, and these have been supplied to patients. Without clinical authorisation, it is of course not possible to import controlled drugs, which is why the drugs were seized by Border Force on Saturday. However, we have made available the opportunity for a second opinion and the products have been held and not destroyed, as would usually be the case.

In relation to childhood epilepsy, the British Paediatric Neurology Association has issued interim guidance. NHS England and the Chief Medical Officer have made it clear that cannabis-based products can be prescribed for medicinal use in appropriate cases, but it must be for doctors to make clinical decisions in the best interests of patients. It is they who have the skill and the training to balance the risks and the benefits of any proposed treatment, including cannabis-based products, and to make a decision with patients and their families on whether or not to prescribe.

To date, research has centred on two major cannabinoids: THC and CBD. There is evidence that CBD may be beneficial in the treatment of intractable epilepsy, and over 80 children have already been supplied with CBD products in the UK on the basis of a specialist doctor’s prescription. I entirely understand how important this issue is to patients, and I have met and listened to the families and know just how frustrated they are. Therefore, after meeting the parents, I have taken the following actions.

First, I have asked NHS England to rapidly initiate a process evaluation to address any barriers to clinically appropriate prescribing. Secondly, to provide the evidence base and to get medicinal cannabis to patients in need, I have asked the National Institute for Health Research and the industry to take action to produce that evidence in a form that will support decisions about public funding. The NIHR has issued two calls for research proposals on medicinal cannabis, and I look forward to responses to those consultations. This is in addition to the training package being developed by Health Education England to provide every support to clinicians to enable them to make the best decisions with their patients.

This is a very difficult area, with some heart-rending cases. I look forward to working with all Members of this House to ensure that patients get the best possible care”.

[Lord Kennedy of Southwark (Lab Co-op)]

My Lords, I thank the Minister for repeating the Answer given in the other place by the Secretary of State to the right honourable Member for Hemel Hempstead. While we are not talking only about children, children having up to 300 seizures a day must leave their parents distraught and desperate. The Government must act much more hastily to ensure people who can benefit from medical cannabis have the means to get access to it on prescription. Can the Minister set out for the House the timescale for the process evaluation announced by the Secretary of State yesterday? This issue has been going on for far too long and needs resolving finally in the next few days.

[Baroness Blackwood of North Oxford]

I thank the noble Lord for his question. The Secretary of State has asked NHS England to act with the utmost urgency and to bring responses forward quickly. I note that this comes in addition to the HEE training model and the NHS England and BSA system to monitor prescriptions for cannabis products. We expect results from that data this month, so we expect more action imminently.

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for the action she is taking. I have some specific questions about what she said. Can she confirm that the second opinion she mentioned will come from a doctor with an appropriate understanding of the safety and effectiveness of these drugs, and that it will be available to all patients in the same situation? Secondly, she mentioned the British Paediatric Neurology Association’s interim clinical guidance, which was made very much as a snap judgment straight after the rescheduling last November; in effect, it just said, “No, no, no”. Can the Minister encourage the BPNA to consider further the massive amount of evidence from abroad and produce more considered guidance? Thirdly, she mentioned the 80 prescriptions for CBD medicines, but that does not strike me as making much progress, because you can get CBD legally on the internet; the only advantage of such prescriptions is getting the drug for free. The issue concerns medicines containing THC, which are the ones that patients desperately need. Finally, the Minister will probably find that trusts are stopping doctors who would like to prescribe these medicines from doing so. Getting the NICE guidance a lot sooner than next autumn would probably encourage trusts to allow their employees to do so. Can she encourage NICE to hurry up, please?

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her question, and I know that she has campaigned on this issue for some time. NHS England has clarified that clinical guidance does not remove or replace the clinical discretion of the prescriber to act. I know that the process review will look at the impact of clinical guidance, which will hopefully be helpful. We will also look at the role of second opinions. I hope that that has answered some of the noble Baroness’s questions; she made a number of points, and I will write to her on the rest.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I want to come back to the point about NICE made by the noble Baroness, Lady Walmsley. My understanding is that, at the moment, the evidence on which doctors can base a decision to prescribe these medicines is very limited. Clearly, relying on the NICE guidance is one way through. My problem is that, if we look at another area such as cataract operations, we see that despite NICE guidance many patients are now being denied treatment that has absolutely proven to be effective. My concern is that the Government seem to be trying to find a way round the evidence relating to these medicines when, up and down the country, patients are being denied interventions that we know will be successful and that can help thousands of people. Can the Minister comment on that?

[Baroness Blackwood of North Oxford]

The noble Lord is right that it is important that guidance is provided. The point of bringing the guidance forward is to look at the most up-to-date evidence available across the country. The challenge with medicinal cannabis is that the evidence base is developing. Currently, more than 100 clinical trials are ongoing worldwide. We are bringing the NICE guidance forward in the autumn to take all that clinical evidence into account in the most up-to-date guidance, so that patients can benefit and clinicians can have more confidence in prescribing. The NIHR call for clinical trials has been brought forward so that the evidence base can be strengthened even further as we go forward because, in the long term, the only way for us to move from an unlicensed prescribing route, which is where we are now, to a licensed route is through clinical trials and a greater evidence base. That is what the Government are keen to encourage.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise that, whenever patients take part in a clinical trial, there will also be some patients who access the medication outside that trial? Are the Government establishing a confidential database to monitor the outcomes of every child who is prescribed a cannabinoid to look at its efficacy and any harms reported, so that we can get a cross-population database of the effects that could then feed into the evidence-accruing processes? It may be that a royal college such as the Royal College of Paediatrics and Child Health would be able to assist the Government by providing a confidential haven for such clinical data to be collected.

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[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her comments, and I know that she is expert in this area. Proposals for an observational trial and the collection of observational data have been put forward. I think that the concern is that, at the moment, there is a lack of confidence in the data. What is needed is the highest quality clinical data because, while a large amount of observational data for medicinal cannabis is available, data at the level of randomised controlled trials is required so that there is confidence not only among clinicians to prescribe but also for the funding system to fund within the NHS. At this point, it is that level of data which needs to be gathered, and that is why the NIHR is bringing forward public funding for it and why the Government are encouraging the industry to fund such trials as you would expect in any other area of the pharmaceutical industry.

[Baroness Hussein-Ece (LD)]

My Lords, I declare an interest in that my grandson has intractable epilepsy, so we have been through the whole process, and I have some understanding and experience of this issue. He has recently been prescribed Epidiolex after a long struggle for him to be allowed to use it. Over the past few months, we have seen some incredible benefits from it. Does the Minister accept that rather unfair barriers have been put in place as regards access to this drug for children? I have heard of other cases where the British Paediatric Neurology Association, which she has mentioned, has said that Epidiolex, which is manufactured without THC, could be used for the treatment of childhood epilepsy as long as all other treatment avenues have been explored, including brain surgery and VNS. My grandson has had this treatment, where a device is attached to the spinal cord. These are incredibly invasive, dangerous and risky procedures. Surely it would be better to allow Epidiolex to be tried out rather than insisting on other routes? One mother told me that they are insisting that her child has brain surgery first. That cannot be right.

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her comments and for setting out her personal experience. She obviously has expertise in this area which few of us in the Chamber can claim. The reason NHS England has put forward is that individual clinical expertise relating to an individual patient is of the utmost importance, even where the guidance might seem to contradict that judgment. That is why in the autumn we will be bringing forward NICE guidance that will look at the most up-to-date evidence which should, we hope, be of assistance. It is also why we are bringing forward the NICE process review in order to understand what barriers may be in place and to encourage clinically appropriate prescribing and try to assist with cases such as these.

[Baroness Warwick of Undercliffe (Lab)]

My Lords, what Mrs Emma Appleby has done—and I praise her courage—is to show that, whatever relaxation there appears to have been or modification, which we all thought was likely to produce some positive results, in fact that really is not happening. People are being denied medication, with incredibly debilitating results. I have an interest in this because I have a young family member with stage 4 terminal brain cancer. He suffers from sickness as a result of chemotherapy which nothing else is able to help. He has been refused cannabis. The consultant will not prescribe it because he feels that there is not enough information from the Department for Health and Social Care for him to feel that he is justified in doing so and he does not know what the implications might be. I understand from another consultant that the BMA is in fact advising medical professionals not to prescribe it. What is the alternative for desperate relatives? Is it to buy cannabis off the streets not knowing what the quality is and facing the prospect of a criminal conviction? Speed is of the essence here, certainly for my family member. I hope that the Minister can say a little more about the way in which this is likely to progress and the speed with which it will do so.

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her question and for describing her personal experience. I emphasise that we must allow clinical decision-making in this. We have tried to encourage more experience in the system by putting out guidance through NICE based on the latest evidence, by providing Health Education England with the opportunity to bring forward training to share the best quality experience, and by putting through the process review so we can bring down any inappropriate barriers in the system. I hope that encourages the noble Baroness.

Tobacco Harm Reduction

Baroness Blackwood of North Oxford Excerpts

Tuesday 2nd April 2019 Lords Chamber

[Viscount Ridley]

To ask Her Majesty’s Government what assessment they have made of the levels of smoking and incidence of lung cancer in Sweden as a result of steps taken by that government; and what plans Ministers have to visit that country as part of their forthcoming review of tobacco harm reduction.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, the current smoking rate in Sweden is 13%, compared to England where the rate is 14.9% and, across the UK, 15.1%. There are no current plans to visit Sweden. Smoking is at the lowest level recorded in England but we are not complacent and remain committed to reducing the rate to 12% or less by 2022, as outlined in the tobacco control plan for England.

[Viscount Ridley (Con)]

My Lords, I thank my noble friend for that reply. She will be aware that the policy of harm reduction, whereby a less harmful new technology is used to displace a more harmful technology, was pioneered in this country by the noble Lord the Lord Speaker when he was Health Secretary in the 1980s with respect to needle exchanges and HIV. Such a policy has since proved effective in the introduction of e-cigarettes. However, in Sweden, the adult smoking rate is now down to 5% because of another harm-reduction technology, snus—the little teabag of snuff tobacco that one presses against one’s gum and is widely used in Sweden. As a result, there are low lung cancer rates in that country but, because snus is banned in the EU, we are currently unable to follow. Could we not save tens of thousands of lives if we were to legalise this technology when we left the EU at the end of next week?

[Baroness Blackwood of North Oxford]

I thank my noble friend for his question and join him in paying tribute to the noble Lord the Lord Speaker’s role in harm reduction. No tobacco product is safe to consume, due to its links to cancers. As my noble friend says, snus is banned under the EU tobacco products directive as an oral product, except in Sweden. We have made a commitment under the tobacco control plan that, following EU exit, the Government will consider reviewing the position on snus and whether the introduction of the product to the UK market would promote the kind of proportionate harm-reduction approach that he proposes. However, there is no evidence that snus in Sweden has reduced smoking rates, so the matter is very much under review.

[Baroness Thornton (Lab)]

My Lords, it is important to say that snus is snuff—let us be quite clear that we are talking about a tobacco product. It seems slightly odd that the noble Viscount should suggest that we swap one very carcinogenic product for one that might be slightly less carcinogenic and will give you only mouth and throat cancer. Will the Minister commit that the review of tobacco regulation will include an assessment of the continuing attempts by major tobacco companies to market their brand identities through advertising campaigns and sponsorship—for example, through Formula 1? Indeed, one of her colleagues recently had to write to Philip Morris, which makes Marlboro cigarettes, telling it to remove poster adverts for “healthier” tobacco products from shops around the UK.

[Baroness Blackwood of North Oxford]

Smoking remains the biggest cause of death in this country. Strict rules are in place to prevent tobacco companies promoting their products, including through sponsorship. We take the unlawful promotion of tobacco products extremely seriously and expect any organisation found to be flouting the rules to be investigated.

[Lord Patel (CB)]

My Lords, although snus contains both nicotine and tobacco—that is why the Swedes use it—the lung cancer rate in Sweden has reduced, whether that is to do with the use of snus or other reasons. That is the main thing that we should be talking about. What strategies do we have to reduce our lung cancer deaths, which run at about 35,000 a year? Tobacco is a key cause—80% of them are related to tobacco. Does the Minister agree that we should think about a strategy for harm reduction, whether it is snus, e-cigarettes or any other product?

[Baroness Blackwood of North Oxford]

I thank the noble Lord, who has expertise in this area, for his intervention. He is absolutely right that we need to target a reduction in lung cancer rates. Cancer Research UK states that smoking tobacco is the biggest cause of lung cancer in the UK, with seven out of 10 lung cancers caused by smoking. The NHS Long Term Plan has a very heavy emphasis on prevention, including smoking cessation services. One of the first interventions from that plan to be rolled out is the innovative targeted lung health check, which will provide an easy-access gateway to lung health and smoking cessation services. I hope that he is reassured by that answer.

[Lord Rennard (LD)]

My Lords, Sweden has banned the advertising of tobacco products, introduced clean indoor air laws and increased the price of cigarettes. Together with the properly regulated promotion of e-cigarettes, have not these measures been shown across the world to be the best methods of tobacco control? Is there not a real danger with products such as snus that tobacco companies want to promote their dual use, pushing potentially dangerous tobacco products in clean air environments and continuing to push traditional tobacco smoking products elsewhere?

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[Baroness Blackwood of North Oxford]

The noble Lord is right. E-cigarettes have proved to be a beneficial aid in quitting smoking, but the best thing that a smoker can do for their health is to quit smoking entirely. That is the priority of the tobacco control plan and the measures that are pushed through the NHS and by other means. In the UK, about 5.5% of adults—about 2.2 million—currently use e-cigarettes. It has proved to be an effective means of quitting smoking, which is why we encouraged this route through the tobacco control plan and will continue to do so.

[Earl Cathcart (Con)]

My Lords, five years ago I smoked 50 cigarettes a day. Then I took up vaping and have not had a puff of tobacco since. Should the Government not do more to encourage smokers to switch to vaping?

[Baroness Blackwood of North Oxford]

I emphasise that smoking is now at the lowest levels recorded, and we should be proud of the fact that the UK is seen as a world leader in tobacco control. However, we are by no measure complacent, because there are variations between different groups and across the country. That is why the NHS Long Term Plan contains a commitment to do more to target smokers in NHS care, why NHS health checks offer an opportunity to smokers to quit, why PHE backs the very successful Stoptober campaign, why we are introducing smoke-free prisons, why we are introducing interventions for those within the mental healthcare system, and why we are introducing a new smoke-free pregnancy pathway. All those things will ensure that we continue to reduce the incidence of smoking in the UK.

[Lord Foulkes of Cumnock (Lab Co-op)]

My Lords, will the Minister look at the experience of Scotland 20 years ago? A factory was opened that produced these small tobacco pouches, but it was closed down within a year—I was one of the people responsible—because of the incidence of mouth cancer. We saw that, in the United States and elsewhere, mouth cancer was caused by sucking those pouches. It really is a crazy suggestion from the noble Viscount.

[Baroness Blackwood of North Oxford]

I thank the noble Lord for his point. I shall certainly look at the experience of Scotland. There will be an evidence-based review, which will look at the risks as well as at the proposals.

Vaccine Hesitancy

Baroness Blackwood of North Oxford Excerpts

Monday 1st April 2019 Lords Chamber

[Lord Faulkner of Worcester]

To ask Her Majesty’s Government what assessment they have made of the report in the European Journal of Public Health on 25 February that there is a link between anti-establishment politics and vaccine hesitancy.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, while there has not been a specific assessment on the link between anti-establishment politics and public confidence in vaccination, we take the issue of misinformation about vaccines extremely seriously and are working across government to tackle this. We are aware of global concerns regarding confidence in vaccinations knowing the protection that they give against deadly diseases, and I am pleased to say that in this country confidence in our vaccines is very high.

[Lord Faulkner of Worcester (Lab)]

I am grateful to the Minister for that positive Answer. She will know that the World Health Organization has declared the anti-vaccine movement as one of the top global health threats for 2019. That follows the tripling of the number of measles across Europe and the sixfold rise in the United States. The paper in the European Journal of Public Health, to which my Question refers, says that there is a direct link between the rise in populist politics and vaccine hesitancy, and cites particularly Greece, Italy and France, and of course one would add the United States as well. There is also much disinformation about vaccines spread on Twitter and other social media. Will the Government make vaccination compulsory as their response to this, as over one-third of countries have done and as we did in Britain in 1853 to combat smallpox? Secondly, what progress have they made in forcing the social media companies to take down this misleading information about vaccines?

[Baroness Blackwood of North Oxford]

I thank the noble Lord for an important question. The UK has one of the most sophisticated vaccination programmes in the world and we constantly guard against threats that may reduce vaccination rates. I am pleased to say that 93% of parents trust NHS staff and advice. The Government recognise the threat posed by disinformation and the upcoming online harms White Paper will set out a new framework for tackling this. PHE’s monitoring data on patient and public trust, however, shows that there is no loss of trust in vaccination, which is to be welcomed. On compulsory vaccination, vaccination programmes in the UK currently operate, like all other medical care, on a system of informed consent. At the moment there is little evidence that compulsion would lead to an increased uptake and so the Government have no plans to introduce such a system but instead intend to work with those who have concerns about vaccination.

[Baroness Walmsley (LD)]

My Lords, any distrust of experts sends out a terrible message to all those young people who spend years of study and thousands of pounds becoming experts. Does not our education system fail unless it produces a population who can properly interrogate scientific evidence?

[Baroness Blackwood of North Oxford]

The noble Baroness is right that we should have great confidence in experts and ensure that young people coming through our education system have that same confidence. This is why we can be proud of the high uptake of vaccinations in this country. A number of key components have achieved the high coverage of vaccination. They include national co-ordination of our vaccination programmes, fully trained staff and access to relevant information. We must ensure that this continues so that high level of confidence among parents and patients continues.

[Lord Lansley (Con)]

My Lords, in the study the noble Lord referred to in his Question, the correlation between populist voting and vaccine hesitancy in the United Kingdom was less than in a number of other European countries, but a study in America demonstrated that what was most likely to lead to a positive response from parents was time spent with paediatricians. That is about finding doctors who have the time to explain the purposes of vaccination and to respond to any parental concerns. Will the Minister look at the extent to which family doctors can have that time incorporated into, for example, their Quality and Outcomes Framework remuneration?

[Baroness Blackwood of North Oxford]

My noble friend is quite right that one of the things that was highlighted in the recent survey about public trust in vaccinations was that 93% of parents trust NHS staff and advice and that 93% of parents remain confident in the immunisation programme. So in order to cover that last percentage, we need to ensure that those parents have access to a GP programme. I therefore encourage parents to speak to their GP or a health professional about vaccinations and to look to credible sources, such as NHS Choices, for their information. I will certainly consider the point raised by my noble friend.

[Baroness Greengross (CB)]

My Lords, by coincidence, tomorrow here in this House I am hosting an event about vaccine policy, specifically about how we improve vaccine coverage in this country because, in spite of what the Minister said, there is room for improvement. Some of us are really quite worried about the decline in some communities and in some parts of the country. Does the Minister agree that much better use of social media is extremely important and necessary if we are to get the positive message about vaccine out there to counter the negative scare stories which do so much harm? Does she agree that more should be made of the intergenerational message? Older people—I refer not simply to Members of this House but to the older population—often have memories of the terrible impact of infectious diseases, whether we are taking about yellow fever, polio or measles. They can tell those who are still young all about them. Surely this will reinforce the importance of the vaccination programme.

[Baroness Blackwood of North Oxford]

The noble Baroness raises a very important point which is that while social media can be used to spread disinformation or misinformation, it can also be used in a positive way to spread the positive value of vaccinations. That is why we want to work with those who have doubts about vaccination to highlight the benefits of vaccinations, the protection that they bring from the very serious diseases which she highlighted and how safe they are. A wealth of information is available online through trusted NHS channels which will enable parents to make well-informed decisions about getting their children vaccinated. I encourage the noble Baroness to highlight in her event next week some of the channels which are available and which we will continue to push.

[Lord Turnberg (Lab)]

My Lords, vaccination programmes are the most effective public health measures we can imagine. I have two questions. First, what are the Government doing to ensure that pharmaceutical companies are encouraged to develop new vaccines for diseases? Secondly, I understand that some schools have made it imperative for parents to ensure that their children are vaccinated before they can attend the school. Is this something that we can extend?

[Baroness Blackwood of North Oxford]

The noble Lord raises an important point. There are global shortages of some vaccines on occasion and, when that happens, discussions with manufacturers are ongoing. There is also ongoing work to develop new vaccines. That is part of the life sciences strategy and sector deal, which the noble Lord may be aware of. Public Health England advises clinicians on how to prioritise available vaccines when these situations occur.

I think that I covered the question of compulsory vaccinations and schools that restrict access to vaccinations in my first Answer. Public Health England and clinicians do not believe that this is the appropriate route, as medical care in the UK is delivered by informed consent. Generally, those who are hesitant about vaccinations respond better to people working closely with them to explain the benefits of vaccines and how safe they are; otherwise, the risk is that children will be withdrawn from schooling entirely, which would be a much worse outcome for the children involved.

Health: HIV

Baroness Blackwood of North Oxford Excerpts

Monday 25th March 2019 Lords Chamber

[Lord Black of Brentwood (Con)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I declare an interest as a trustee of the Bloomsbury Network.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, due to increased access to testing and other measures, there has been a welcome 28% decline in new HIV diagnoses since 2015. We are also one of the first countries in the world to meet the UNAIDS 90-90-90 HIV targets. To build on this progress, the Secretary of State for Health and Social Care has announced the Government’s commitment to end new transmissions of HIV in England by 2030. Work is under way to take this forward.

[Lord Black of Brentwood]

I thank my noble friend for that Answer. I know that noble Lords across the House who have long campaigned for this moment—I am hazarding a guess that I might include the Lord Speaker in view of his exceptional leadership in this area—will applaud the Secretary of State’s commitment to eliminating new HIV transmissions by 2030. In the certain knowledge that those with HIV on effective treatment cannot pass it on, it is now in our power to bring an end to this cruel illness. Does my noble friend agree that what is needed now is a comprehensive national HIV strategy, which brings together all of the steps that we need to take: prevention through both sustainable access to PrEP and effective treatment for those diagnosed; more testing to stop late diagnosis; greater investment in sexual health services; education about HIV in schools; an end to the fragmentation of HIV services; and a commitment to tackle stigma?

[Baroness Blackwood of North Oxford]

I thank my noble friend for that Question and pay tribute to the work of the Lord Speaker. I agree with the premise of his Question. Public Health England has attributed the success that we have had, with 92% of people with HIV now diagnosed, 98% of patients receiving treatment and 97% virally suppressed to a combination of HIV prevention, including expanded HIV testing, prompt initiation of antiretroviral therapy after diagnosis, condom provision and PrEP, all of which we will need to build on as we develop plans to achieve zero infections by 2030. He is absolutely right that these will all need to go into development of that plan.

[Baroness Thornton (Lab)]

My Lords, it is greatly to be welcomed that science is now leading us to end new transmissions by 2030. But is the Minister aware that women who are HIV-positive are four to five times more likely to develop cervical cancer? I agree with the noble Lord that there is a need for a new strategy. Will the forward plan and investment in public health recognise the need for investment in prevention and early intervention and a package of care for all women living with HIV, which includes going for regular smear tests?

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her question. She is absolutely right that the key to us making progress is prevention and early intervention and also understanding about any crossover consequences with other illnesses. She is also right that the key is closing the gaps now. In 2017, 43% of diagnoses were made at a late stage of HIV and, although there has been a decline, the largest group diagnosed at late stage were black African heterosexual men and women. It is important that we close those gaps. Some key projects have been working on that through the HIV Innovation Fund so when we bring forward plans for HIV 2030 it is important that we find out how we can close those gaps if we are indeed to get to zero by 2030.

[Baroness Barker (LD)]

My Lords, does the Minister agree that in order to end HIV by 2030 all children need to understand their own risks through comprehensive relationship and sex education and that schools that refuse to teach it are jeopardising the health of all pupils? Does she agree that that should not happen?

[Baroness Blackwood of North Oxford]

Knowledge about safer sex and sexual health is essential for young people. They must be equipped to understand and to make safe, informed and healthy choices. That is why we have brought in compulsory SRE for the first time, which all schools should be required to teach.

[Baroness Hayman (CB)]

My Lords, as well as the very welcome national strategy that the Minister described, will she accept that this is a global problem? In other parts of the world, progress has not been as great as it has been here. We need to see that progress. In that respect, does she recognise the work that the Global Fund to Fight AIDS, Tuberculosis and Malaria has had on reducing incidence worldwide of these killer diseases? Will she commit for the Government to be active in their leadership in the replenishment of the Global Fund this year?

[Baroness Blackwood of North Oxford]

We can be incredibly proud that the UK is a world leader in efforts to end the AIDS epidemic, including through our huge investment in the Global Fund, which has provided 17.5 million people with treatment since 2017, and of course through DfID’s research on HIV prevention. That is exactly why DfID has committed to continuing its focus on HIV prevention technologies and I am happy to share that commitment with the noble Baroness.

[Lord O'Shaughnessy (Con)]

My Lords, may I echo my noble friend Lord Black’s praise for the Secretary of State’s ambition and associate myself with his policy suggestions? My noble friend will be aware that there is a similarly infectious, life-limiting disease that affects similar people, called Hepatitis C. We now have a cure for that disease: we are able not just to eliminate it as a public health risk but actually to cure people. In drawing up any strategy, will the Minister ensure that the department also makes sure that curing Hep C and making that cure available to those people is as big a priority as eliminating HIV?

[Baroness Blackwood of North Oxford]

I thank my noble friend for his question and also for his leadership on this issue while he was in the department. He knows that the Government are committed to being a world leader in domestic eradication of Hepatitis C. He will know also that a legal challenge by AbbVie delayed the start of contracts on this issue by six months. I am pleased to be able to inform the House, however, that in January the High Court found in NHS England’s favour on all grounds in this matter. We can now go forward with those innovative contracts, which are worth about £1 billion over five years. That will be rapidly put in place over the coming months, which will allow us to make progress on this matter.

[Baroness Tonge (Non-Afl)]

My Lords, although I congratulate the Government on the progress they have made in the diagnosis and treatment of HIV, does the Minister realise that women in this country have an ever-decreasing service for cervical cytology and, indeed, for having those smear tests read in laboratories, given that the number of laboratories is being decreased? Does she realise also that, because of cuts in local government funding, there are very few family planning clinics now, either for women or young girls? That means that the provision of contraception is very limited, because they have to go to their GPs.

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for that probing question. The Government have mandated local authorities to commission comprehensive open access sexual services. We have continued the ring-fence around public health services in local authorities at £3 billion a year and they have maintained 3 million attendances in 2017, which is an increase since 2016. What is important is that the long-term plan has also identified sexual health services as an area for review going forward, which is one of the findings from PHE. This is therefore a cause for encouragement, and I hope that the noble Baroness will be reassured.

Child and Adolescent Mental Health Services

Baroness Blackwood of North Oxford Excerpts

Monday 25th March 2019 Lords Chamber

[The Lord Bishop of Newcastle]

To ask Her Majesty’s Government what action they are taking to improve children’s and young people’s access to mental health care.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, the NHS is on track to meet the Five Year Forward View for Mental Health commitment that 70,000 more children and young people will access treatment each year by 2020-21. Under the NHS Long Term Plan, a further 345,000 children and young people will receive support by 2023-24. Our recent Green Paper sets out our plans to pilot a four-week waiting time for specialist NHS mental health services for children and young people.

[The Lord Bishop of Newcastle]

My Lords, I thank the Minister for her remarks and welcome the commitment to prioritising investment in mental health care for children and young people. However, data published by the NHS in November showed that only one in four young people with a mental health disorder accessed specialist mental health services in the previous year. I welcome plans from the Government to increase this figure to 100% within the decade, but given that three-quarters of children with a diagnosable mental health condition do not currently get access to the support they need, how will the Government act to help this generation of children who will have moved on to adult services before this rollout is complete?

[Baroness Blackwood of North Oxford]

I thank the right reverend Prelate for her very important question. We are coming from a low base in children’s and young people’s mental health services, and successive Governments have failed to prioritise these services as they should have. That is exactly why the long-term plan sets out our determination to address this—to ensure that all children get the care they need. With more money, more staff and more beds, there will be £2.3 billion a year more for this area by 2023-24, a figure that is growing faster than the rest of the NHS budget. It is why the NHS and HEE are targeting to recruit 8,000 more children’s and young people’s mental health staff, and why we are bringing in the first ever access and waiting services. I accept, however, that the pace at which this is going is frustrating, but it is important to understand the base from which we are coming.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on pace, will the Minister acknowledge that this Government and their predecessor, the coalition Government, have made any number of promises about investment in and prioritisation of mental health services, particularly for children and young adults, but that when it comes to the decisions made by clinical commissioning groups, the reality is that they have not brought them to fruition? What guarantees do we have that this time clinical commissioning groups will do what they have been asked?

[Baroness Blackwood of North Oxford]

The noble Lord, Lord Hunt, is very experienced in this area and has been involved with local clinical commissioning groups. The NHS has already opened 117 additional new mental health beds, and we have introduced new waiting standards for psychosis and eating disorders among children. Progress is already being made, but we should not dismiss the frustrations of those trying to access services. That is why we have put in place ambitious new targets with the long-term plan: we want to see 100% of children able to access the care they need.

[Baroness Hollins (CB)]

My Lords, about two-thirds of children with autism and two-fifths of children with special educational needs experience mental health problems. But the provision of specialist clinical community child learning disabilities services is sparse. What are Her Majesty’s Government doing to ensure that the needs of those vulnerable young people are planned for in the new funding allocation?

[Baroness Blackwood of North Oxford]

The noble Baroness is right: those with particular needs, where autism or learning disabilities cross over into mental illness, must be taken into account. Some distressing figures show that those with learning disabilities do not get the physical health assessments that they need either. This must be taken into account and is in part why the children and young people’s Green Paper puts in place designated senior leads for mental health in schools and mental health support teams in and around schools, so that those needs can be identified as early as possible, and we can prioritise prevention and early identification of mental health needs when they arise.

[Baroness Redfern (Con)]

My Lords, the first mental health support teams will be set up in 25 trailblazer areas, of which 12 will also trial a four-week waiting time. Will those teams be in partnership with local authorities and the relevant CCGs, and who will monitor and evaluate the outcomes?

[Baroness Blackwood of North Oxford]

The outcomes will be monitored by NHS England, but also by the CCGs. Of course, they will be taken into account by local authorities as well.

[Baroness Tyler of Enfield (LD)]

My Lords, given the fragmentation and lack of co-ordination on the ground between local mental health services, what assessment have the Government made of the potential benefits of establishing local offers for mental health, mirroring the approach to local offers for special educational needs introduced by the Children and Families Act, to improve access?

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[Baroness Blackwood of North Oxford]

The noble Baroness is very expert in this area, and I thank her for that interesting proposal. I should like to take it back to the teams in the department and write to her on that point, if that would be okay.

[Lord Touhig (Lab)]

My Lords, I have been told that the Government expect every health body to provide a seven-day specialist multidisciplinary service to prevent people with autism needing in-patient care. That has been government policy since 2015. In the last four years, there has been a 24% increase in autistic people without a learning disability being placed in mental health hospitals. What are the Government doing about this policy failure?

[Baroness Blackwood of North Oxford]

The noble Lord raises an extremely important and difficult area of service. This is exactly why the Government have just launched a review of autism services, which is currently open for consultation. We are trying to improve these services as we speak.

[The Earl of Listowel (CB)]

My Lords, as a trustee of a mental health service for adolescents—the Brent Centre for Young People—I welcome the additional funding the Government are bringing forward. Is the Minister aware, however, that one of the most effective ways of preventing children having to access mental health care is supporting, for instance, groups of adoptive parents, foster carers or head teachers, with a senior clinician? However, there is concern that many senior experienced clinicians have been lost because of the shortage of funding. Will the Minister look at what she can do to stem that loss, find out what the issue is, and do what she can to invest in that area as well?

[Baroness Blackwood of North Oxford]

I thank the noble Earl for his question. Obviously, recruitment aims in the mental health service are essential, and the workforce plan sets out an aim for 600 full-time posts in mental health. We have already discussed the Government’s plan in the Green Paper to set up 8,000 new children’s and young people’s posts in mental health. But that is no good if we are not also retaining those staff. NHS Improvement and NHS Employers are now working to ensure that all mental health trusts are given the tools to drive improvements in retention. This is a programme that has seen improved turnover, and we shall keep monitoring it to ensure that we retain the staff we work so hard to recruit.

Healthcare (International Arrangements) Bill

Baroness Blackwood of North Oxford Excerpts

Report stage (Hansard): House of Lords
Tuesday 12th March 2019 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I am privileged to follow my noble friend Lord O’Shaughnessy, and I am sure that Peers from all sides of the House will have been impressed by the thoughtful letter which the Minister has sent to us all. In it, there are a number of concessions, which will be subject to later amendments in this debate. The insertion of a sunset clause is a valuable safeguard, as are the requirements that arrangements are limited to a public authority, and the statutory duty to report to Parliament on an annual basis. All of these are important concessions. Finally, on the Henry VIII clause, the Minister’s letter refers to removing the powers in the Bill to make regulations containing consequential amendments to primary legislation. Individual healthcare waits for nobody.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, I am grateful to the noble Baronesses, Lady Thornton and Lady Jolly, and to the noble and learned Lord, Lord Judge, the noble Lord, Lord Marks, and the noble Earl, Lord Dundee, who I am sorry could not be with us today, for giving me the opportunity to deal with the important matter of the global nature of the Bill. We have already had a good deal of debate about this during our progress on the Bill, but it is a pleasure to return to it today yet again.

It is important that the Government explain why we believe it appropriate to seek powers which are global in nature. As I mentioned in my response in Committee, the EU Home Affairs Sub-Committee of this House, which is very wise, remarked that:

“Reciprocal healthcare oils the wheel of the day-to-day lives of millions of citizens”,


and brings the,

“greatest benefit to some of the most vulnerable members of our society”.

I am grateful to noble Lords from across the House, not only in the debate today but during the progress of this Bill, who have been clear that there is widespread cross-party support for the current EU arrangements, and for providing the people who rely on these arrangements with the assurance that the Government are taking all the necessary steps to support them in these uncertain times.

We clearly all support the arrangements we have with the EU. It therefore does not seem logical to preclude the possibility of seeking new arrangements or strengthening existing ones outside the EU. Where the Government have a good policy in one place, it seems logical that we should want to extend it to others. Reciprocal healthcare agreements promote tourism and facilitate economic exchange and growth by enabling people to study, travel and work abroad without worrying about their ability to access healthcare, or the cost of doing so. As we have discussed in our debates on this issue, reciprocal healthcare arrangements are particularly important for older people, people such as me with chronic conditions, or people with disabilities, for whom access or costs can be a genuine barrier to travelling.

Reciprocal healthcare agreements enable people to travel overseas for planned treatment, which enables patient choice. One of the genuine benefits of the current EU arrangements is to enable mothers to travel to a home country to give birth close to their families and support networks. That is available only to EU citizens at the moment, not to those from other countries who live here. Our existing arrangements with the EU enable around 1,350 UK residents to receive planned treatment or maternity care in another EU member state. We do not want to be forced to limit choices only to EU countries in the future.

Reciprocal healthcare agreements can also help to support international healthcare co-operation through fostering closer working relationships between countries and states. We can be proud that the UK is a prominent voice in the global healthcare community and is a key driver in global attempts to raise standards of patient safety. We could help to further drive that agenda through developing even stronger relationships with our close partners. I have heard the concerns raised by noble Lords about the costs of these arrangements. Reciprocal healthcare agreements enable countries to reimburse one another on a fair and transparent basis. Noble Lords, particularly the noble Lord, Lord Foulkes, have queried why we cannot simply rely on waiver agreements. Fair reimbursement is the key reason why. Without this Bill, we would be restricted to waiver agreements outside the EU without a way to establish fair and transparent payment and cost-recovery mechanisms.

Agreements with other countries predate the EU and have never been limited to Europe. This is one reason why the concept of restricting the Bill to the EU does not make sense. We have agreements outside the EU now and will continue to have them in the future. The noble and learned Lord, Lord Judge, and my noble friend Lord Ribeiro raised the matter of scope—the countries which the Bill would apply to. As Clause 4 sets out, data can be shared only in accordance with the GDPR and our data protection regulations. This means that no reciprocal healthcare agreement could be reached with a country that does not meet data adequacy standards. Over and above that, as my noble friend rightly noted, this scope would be further narrowed by the need to agree reciprocal healthcare arrangements only with countries that have a compatible healthcare system. This would mean that countries such as Venezuela, raised by the noble and learned Lord, Lord Judge, would simply be out of scope for an international healthcare agreement. Safeguards built into the Bill would be in place.

I make it clear that I have heard the concerns raised at Second Reading and in Committee about the global scope of the Bill and the breadth of the delegated powers. We have taken considerable steps to address the concerns about the breadth of the powers—the root cause of the concern about the global scope. As has already been referred to, we have tabled a large package of concessions, which I worked hard to try to deliver. The first was to remove the consequential Henry VIII powers; I am taken by the terminology for this now being a “Blackwood amendment”. We have limited the ability to confer functions to public bodies. We have provided greater parliamentary scrutiny over regulations relating to data processing and greater transparency over the financial aspects of future reciprocal healthcare policy in the form of an annual report. I hope that this reassures the noble and learned Lord, Lord Judge. We have placed a statutory duty to consult the devolved Administrations where regulations make provision within devolved competence. Finally, and very significantly, we will sunset two of the three regulation-making powers at Clause 2, so that they can be exercised only for a period of five years after exit day. This final amendment means that it is not possible for the Secretary of State to set up any kind of long-term scheme to unilaterally fund mental health treatment in Arizona or hip replacements in Australia, as the DPRRC proposed. In tabling these amendments, we have limited the delegated powers and therefore the scope of what can be done under the Bill around the world. We have also provided additional parliamentary scrutiny mechanisms and greater transparency.

During the debate on Amendments 1, 2, 11, 12, 13, 27, 28 and 29, from the noble Baronesses, Lady Thornton and Lady Jolly, the noble and learned Lord, Lord Judge, and my noble friend Lord Dundee—who cannot be in his place—I have not heard any concerns raised on the fundamental principle of reciprocal healthcare in countries outside the EU. Rather, I have heard the need for reassurance that in implementing agreements with other countries we seek to appropriately cost such arrangements, protect the NHS, and ensure that those countries which we strengthen or make new agreements with have appropriate healthcare systems and are able to process data appropriately. We are firmly committed to all these principles.

When the Bill was debated in the other place, questions were raised concerning the possibility of a reciprocal agreement with Guernsey, which is something we will need to look into following EU exit. This was seen as a positive possibility of the Bill; it is just one example of how our relationships might evolve and how the Bill can offer people new opportunities which they are currently denied under our legislative framework. If the scope of the Bill is limited to matters relating only to EEA countries and Switzerland, the Government would be unable to implement a reciprocal healthcare agreement with countries such as Guernsey where we are able to reimburse one another fairly. We would also be giving up the opportunity to support people, to bring them confidence and comfort outside the EU.

As the UK considers its relationship with the rest of the world, it is appropriate to take this opportunity to consider strengthening our existing agreements while exploring possible agreements with other countries. The powers under this Bill allow us to fund healthcare overseas to support UK nationals who live in, work in, study in, want to visit or give birth in other countries, while ensuring that we also have appropriate scrutiny powers within this Bill. They also allow us to extend similar opportunities to overseas nationals to use the NHS funded by their own country, making the NHS more sustainable and fit for the future. This is what we would be giving up with these proposed amendments.

There has been much debate in this House and outside it about whether there should, in fact, be two separate Bills: one to provide for implementing agreements with EU, EEA countries and Switzerland, and the other at a later date to provide for countries outside that group. I believe that this is the intent of Amendment 4, in the name of the noble Lord, Lord Marks. That would not be an effective use of parliamentary time; it would prove a barrier to the development and implementation of policy in this area that is clearly in the interests of the people whom I have already discussed. I am also not clear how different a different implementing Bill would look, as it would simply be for the implementation of international healthcare agreements and would be rather similar, whether they are for the EU country or for a country in another part of the globe. It seems to be doing the same work twice.

With the Bill, we seek to ensure that we have an implementing mechanism for reciprocal healthcare now and into the future. While it may be appropriate in other policy areas for the Government to seek new primary powers to implement specific, individual international agreements, it is simply not the case with reciprocal healthcare agreements. These agreements are not far-reaching in nature and are very limited in subject matter: they are about reciprocal healthcare. As has already been discussed, the Government already rely on the royal prerogative to enter into these agreements with other countries. This Bill is simply a smarter implementing mechanism for these agreements.

I also have concerns that Amendment 4 risks our ability to effectively implement a future relationship with the EU. Recognising the broader benefits of reciprocal healthcare, we want a long-term relationship with the EU but, as with any area of policy, we must have flexibility as to how we negotiate with the EU and how we arrange our broader relationship with it. EU law evolves and, as we discussed in Committee, there are proposals currently before the European Parliament that would mean that elements of that model might change in the near future. This amendment would prevent the UK from implementing that evolved arrangement even if that was the desired negotiating position of the UK. If we put this on the face of the Bill, we would have no flexibility on how we would do that, including agreements already concluded with Switzerland and the EEA and EFTA states. The noble Lord himself acknowledges in his amendment that flexibility is needed, but through this amendment that flexibility would be difficult to apply in practice.

In relation to all the amendments in this group I firmly believe that, in pursuing future reciprocal healthcare policy with close partners outside the EEA and Switzerland, the Government are providing hope and opportunity to people. Our colleagues and friends in the other place overwhelmingly supported this endeavour. We have introduced significant restrictions on what this Bill can do globally. However, I regret that these amendments would prevent us from being able to look to the future and embrace an opportunity for EU exit. It would be a great shame to miss that opportunity.

I recognise the valuable contributions from many Members of the House on enhancing and improving many elements of this Bill; I thank them for the time that they have given me, but I am unable to accept these amendments. I hope noble Lords will feel able not to press their amendments on that basis.

[Baroness Thornton]

I thank the Minister for her remarks and for the attention that she has paid to this matter all the way through. Everybody appreciates that enormously. In a way, she has made my argument for me, as has the noble Lord, Lord O’Shaughnessy, because nothing in the Bill says that healthcare agreements have to be reciprocal. In a way, that proves that we do not need an international healthcare arrangements Bill: we need a European Union-EEA healthcare Bill to deal with reciprocal arrangements and do the job that we have in front of us.

I do not accept the argument put by the noble Lord, Lord O’Shaughnessy, tugging at our heartstrings, about the human consequences of this. Actually, there is nothing to stop the Government bringing forward a global healthcare Bill. I am absolutely sure that the Minister and her colleagues, with the help of the noble Lord and others, could get this into the Queen’s Speech in two months’ time, when we could have all these discussions about how it might work. He said that we do not have any disagreements in principle about this. Actually, we do not know whether we have any disagreements in principle about international healthcare because we have not had that discussion: that is the discussion we would have if we were dealing with a Bill that was being consulted upon, going through pre-legislative scrutiny and all those other things that we have been arguing need to happen if we are to have a Bill of the scope that the Minister and her party wish to have.

I thank the noble and learned Lord, Lord Judge, the noble Lord, Lord Marks, the noble Baronesses, Lady Brinton and Lady Jolly, and my noble friends Lord Foulkes and Lord Judd for their support. In particular, I thank the noble Lord, Lord Wilson, who, in his brief remarks got the argument absolutely right yet again. As I was preparing for this, I looked at the agreements we have with Australia and New Zealand, for example. These things are complicated—of course they are— and in a way that is why they deserve and need further consideration. I fear that we are not convinced by the Minister’s arguments and I would like to test the opinion of the House.

--- Later in debate ---

[Lord Hope of Craighead (CB)]

My Lords, I think that the noble Lord is right in saying that we are establishing a precedent, but I have been looking at the word “example”, and wonder whether the Minister has examples of this kind of legislation being used elsewhere. I cannot think of any. I examined the withdrawal Bill, which was very wide-ranging, and as far as I can recall this phrase does not appear in it even though it contains many provisions about delegated legislation. It would, therefore, be helpful to me if it was demonstrated that this is not the kind of precedent that has been described. In general, however, I congratulate the Minister and her Bill team on going a very long way to meet our objections in later parts of the Bill. I am, however, worried about this bit of it and would like to be reassured.

[Baroness Blackwood of North Oxford]

My Lords, I thank the noble Lord, Lord Marks, for tabling Amendment 3 and the noble Baroness, Lady Thornton, for Amendment 5, both of which seek to place limits on the powers in the Bill.

I will first address the noble Baroness, Lady Thornton, the noble Baroness, Lady Jolly, and the noble and learned Lord, Lord Judge, on Amendment 5, and clarify the purpose of Clause 2(2). We have had some debate about this already but this will be helpful. Clause 2(2) is intended to be an illustrative list of examples of the type of provision that may be included in regulations made under Clause 2(1). It is not itself intended to be a delegated power. The intention has always been to be prudent and transparent in the use of the delegated legislation, and the list was included to be helpful, by demonstrating the types of provision that the regulation-making powers at Clause 2(1) could enable, in order to effectively implement international healthcare regulations in the same way as under reciprocal healthcare regulations. This is not uncommon in primary legislation.

The list is reflective of the kind of provision already included in our current, more comprehensive, reciprocal healthcare arrangements with the EU, and it is intended as a guide to how the powers in Clause 2(1) can be exercised. Regulations under this clause need to be able to do everything that they might need to do to provide healthcare outside the UK, or to give effective agreement. I described in some detail during our debate on this clause in Committee why each of the descriptive lists were included and what they would be used for.

This amendment could mean that future Administrations would be unable to effectively implement reciprocal healthcare agreements with the EU, individual member states or other countries. The reason for this, which has already been alluded to in the debate, is that we have not yet concluded those negotiations and so it is not possible to rule out what we may need to provide for in regulations to give effect to an agreement. In addition, it would not be appropriate to circumscribe in the Bill the Government’s negotiating mandate with the EU, EU member states or countries outside the EEA and Switzerland.

The examples in Clause 2(2) are not exhaustive, but they are useful pointers to aid understanding of how Clause 2(1) is capable of being exercised. I think they have served their purpose, given that we have had such robust debate about them. They offer additional transparency and assistance in understanding how the regulation-making powers in Clause 2(1) would work for the purpose of implementing reciprocal healthcare agreements. This is not an unusual statutory construction; there are examples of where regulation-making powers are accompanied by illustrative lists of what may be included in regulations in order to provide assistance in the understanding of what the powers are capable of doing. As to whether those illustrative lists include the words “for example”, I have an example from Clause 11(2) of the Automated and Electric Vehicles Act 2018, which states:

“Regulations under subsection (1) may, for example—”,


include paragraphs (a), (b) and (c). That is perhaps a helpful example for the noble and learned Lord, Lord Hope.

As this important policy area continues to develop and progress both in the EU and outside the EU, it is appropriate for the Government to be able to respond to protect the continuity of care of those already in receipt of reciprocal healthcare, as well as to explore whether we would like to extend it to others. Were we to accept this amendment, it would, as I said on the previous group, restrict the implementation of reciprocal healthcare arrangements to current processes. That is clearly inappropriate when implementing dynamic agreements in which there are two parties.

Regulations under Clause 2(1) need to be able to do everything they might need to do to provide for healthcare outside the UK or give effect to a healthcare agreement. One small example of why it is right that the Government retain the ability to do this is developments in IT or new technology. As technological change continues to gather pace, it is right that the Government should be able to make the best use of those changes and ensure the most effective and efficient systems for the people accessing these arrangements. That is why we might need to bring in another regulation-making power. I hope the noble Baroness, Lady Thornton, as a former Health Minister, would agree that technology has the power to change the way people access healthcare and can make a real difference in people’s lives, especially perhaps those who are restricted from accessing healthcare because of long-term conditions or distance from services.

While the illustrative list at Clause 2(2) does not expressly make reference to this matter, it may well be necessary to make arrangements to ensure that the most effective and efficient technological processes and systems are incorporated into the implementation of future reciprocal healthcare agreements. The Government are working, through this Bill, to ensure that we have the necessary ability to implement future international healthcare agreements with both EU and non-EU countries.

Amendment 3 in the name of the noble Lord, Lord Marks, speaks to concerns about the breadth of the powers in the Bill. Clause 1 follows a long line of general payment powers found in primary legislation, further to the Public Accounts Committee’s concordant that government expenditure should flow from a specific Act of Parliament. It is a free-standing payment power and needs to be so. Notwithstanding that, we have deliberately chosen to include a power in Clause 2(1) that can be used to support the exercise of the payment power. Therefore, it is not possible for the Government to accept this amendment. Indeed, the DPRRC recognises that general payment powers are not delegated powers.

As I said in my response to this amendment in Committee, the Bill is making good progress through Parliament but clearly will not have Royal Assent until later this month. So, with the best will in the world, we will not be able to lay regulations until the summer. However, in the undesirable, unprecedented situation of no deal, we may need to use these powers before then. That would be specifically for a scenario concerning citizens’ rights agreements with the EFTA states and with Switzerland, which will protect reciprocal healthcare for people living in those countries on exit day, or in other specified cross-border situations.

It is good news that we have operative agreements in the context of no deal, as they will guarantee healthcare for those covered by them. It is likely, though, that we will need to use the power in Clause 1, together with Clause 4, to temporarily implement those agreements. We cannot therefore accept the amendment because we would not be able to protect the healthcare arrangements of people in those countries. We will bring forward further detail in coming weeks when we can be clearer about bilateral agreements, and on the need for any further arrangements. I hope that noble Lords will agree that the Government must have the ability to provide for people at this unprecedented time. I emphasise that stand-alone funding powers such as those in Clause 1 that operate without the need for delegated legislation are not unusual—so this is not being brought in simply because of a no-deal situation.

I have listened carefully and considered the comments of noble Lords about concerns about the scope and breadth of the power. That is why we have sought to address concerns about it, with a large package of amendments to which I have already referred. We have specifically limited the delegated powers and the scope of what can be done under the Bill, and provided additional parliamentary scrutiny mechanisms and greater transparency.

Finally, I will speak to government Amendments 6, 7 and 8. They are in direct response to the concerns raised that regulations under the Bill could be used to confer functions on anyone, anywhere. It is understandable that noble Lords raised the possibility that the regulation-making powers in Clause 2 could be extended to confer functions on private bodies. There is not and has never been an intention to confer functions on private bodies in order to implement reciprocal healthcare arrangements. This was always the case but, given the concerns raised, we are taking action to make this clear.

The proposed government amendments limit Clause 2 to the operation of Clause 2(1) to ensure that any conferral or delegation of functions may only be to a “public authority”. The definition of “public authority” is a person who exercises a function of a public nature. This ensures that public bodies maintain autonomy over how services are procured, contracted and delivered. When making regulations to implement such healthcare agreements, we wish to confer relevant functions on appropriate public bodies according to their part, giving them clear legal responsibility and an operating mandate. Our amendment does not prohibit us from doing this.

I therefore hope that noble Lords will withdraw or not move their amendments.

[Lord Marks of Henley-on-Thames]

My Lords, I shall seek leave to withdraw my amendment, because I feel very much under pressure from what the Minister has just said. It is the case that the free-standing power is needed, as she said, because of the delay that there has been in order to ensure that the payment power can be used before regulations can be laid. My amendment would therefore imperil the continuation of our current European arrangements. I feel under pressure because it the wrong way to do this. It is a great shame that this legislation was not introduced timeously, but I do not wish to divide the House on my amendment and I beg leave to withdraw it.

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Moved by

[Baroness Blackwood of North Oxford]

6: Clause 2, page 2, line 1, leave out “on the Secretary of State or on any other person”

--- Later in debate ---

Moved by

[Baroness Blackwood of North Oxford]

9: Clause 2, page 2, line 8, at end insert—
“(6) No regulations may be made under subsection (1)(a) or (b) after the end of the period of five years beginning with exit day.”

[Baroness Blackwood of North Oxford]

My Lords, the Bill’s delegated powers and their global application have been a source of spirited debate since this Bill’s introduction, and noble Lords have rightly given considerable scrutiny to this matter. A number of amendments were tabled in Committee, including those by the noble Baronesses, Lady Thornton and Lady Jolly, the noble Lords, Lord Patel, Lord Kakkar and Lord Marks, and the noble and learned Lord, Lord Judge. This issue has concerned Peers across the House. I am pleased to say that the Government have listened carefully and tabled an amendment that significantly curtails the scope of the delegated powers in the Bill.

Amendment 9 directly addresses the concerns raised by restricting the exercise of the delegated powers, and, as we have already discussed, limits the global scope. The Bill is intended to support the implementation of comprehensive reciprocal healthcare arrangements with countries within and outside the EU, and to implement possible future partnerships. It was drafted to fulfil this purpose in a number of different scenarios, and that remains the Government’s intention, but we have listened closely to the points raised by Peers both inside and outside of this Chamber, as well as to the views of the DPRRC and the Constitution Committee, and concluded that the regulation-making powers that can be used to set up schemes for unilateral healthcare overseas should be time-limited.

The powers in Clause 2(1)(a) and Clause 2(1)(b) would primarily be needed, in the event of a no deal, to mitigate any detrimental effects of a sudden change in healthcare access for UK nationals living in the EU. These powers would be required in the event that reciprocal arrangements are not in place. Our aim remains to reach an agreement on reciprocal arrangements, but as a sensible Government, we need to plan for all eventualities.

In the unprecedented event of leaving the European Union with no deal, we would need to have the option of establishing support mechanisms for people in exceptional circumstances where there would be a serious risk to their health should any member state not agree to maintain reciprocal healthcare. However, we have listened, and want to ensure that while the Government have the ability to provide for people in this unprecedented time, we are still respectful of the constitutional roles of Parliament and the Executive. In response, we feel that the delegated powers that implement healthcare arrangements outside of reciprocal healthcare agreements with other countries should be sunsetted.

During the five years before the sunset, we will retain the flexibility to deal with exit scenarios using regulations under Clause 2(1) as appropriate. These powers can be used to offer UK nationals reassurance and certainty, which we intend through this Bill. After the sunset, making use of the regulation-making powers under Clause 2(1) would be limited to Clause 2(1)(c) only, which provides the Government with a mechanism to give effect to future complex global healthcare agreements. However, it is important to state that this amendment will mean that it is not possible for the Secretary of State to set up any long-term scheme to unilaterally fund mental health treatment in Arizona or hip replacements in Australia, as has been suggested. Of course, this is not something a reasonable Government would intend to do, but I am happy to provide that reassurance. However, we would want to remove any perceived risk regarding this power, and that is the intention of this amendment.

In tabling the amendment, the Government have sought to clarify the intended use of the important powers in Clause 2(1)(a) and (b). This represents a significant restriction of the Government’s use of delegated powers, in direct response to concerns raised by parliamentarians across this House. It also represents a significant check on the global scope of the Bill. On that basis, I beg to move.

[Lord Lansley (Con)]

My Lords, my noble friend will forgive me if I ask for a point of clarification. If Amendment 9 is passed, after the sunset clause is implemented, powers could only be made in relation to a healthcare agreement. However, Clause 3 says that a healthcare agreement can concern either healthcare provided outside the United Kingdom and paid for by the United Kingdom, or healthcare provided in the United Kingdom with another country paying. It does not require reciprocity. Is that quite the restriction my noble friend was suggesting, since it could still be unilateral, not reciprocal?

[Baroness Thornton]

I thank the Minister for tabling this sunset clause; she is quite right to do so. I had not thought of the question asked by the noble Lord, Lord Lansley, but it is a good one. However, we support the amendment.

[Baroness Blackwood of North Oxford]

I thank my noble friend Lord Lansley for his question. This power enables a unilateral scheme, so it does not require reciprocity and is intended to be used only in an emergency scenario where a group of individuals are in difficulty. That is why it is appropriate to sunset it in this way.

I thank the House for its support for the amendment and hope that the noble and learned Lord, Lord Judge, will withdraw his amendment on that basis. I beg to move.

Amendment 9 agreed.

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Moved by

[Baroness Blackwood of North Oxford]

18: Clause 5, page 3, line 38, leave out subsection (3)

[Baroness Blackwood of North Oxford]

My Lords, I now turn directly to the Henry VIII powers of the Bill. As noble Lords know well, the inclusion of the consequential Henry VIII power in the Bill has been the subject of animated debate both inside and outside this Chamber. The Government have been listening closely to these concerns in the Chamber but also in the reports from the DPRRC and the Constitution Committee. In response, we have tabled Amendments 18, 19, 20, 24 and 25, which is a significant step and addresses these concerns directly.

This group of amendments removes Clause 5(3) and amends Clause 5(4). As a result, it will now not be possible to make consequential amendments to primary legislation using regulations made under the Bill.

I want to be clear that the consequential Henry VIII powers were initially included as a future-proofing mechanism. They were never free-standing and we had envisaged using them in only a limited set of circumstances. As negotiations have not yet concluded and the terms of any agreements are not yet settled, there may be situations where it would be appropriate to amend primary legislation. This is why the power was included. We cannot rule out that we may want to amend primary legislation to give effect to a reciprocal healthcare agreement in future, and the lack of such a future-proofing mechanism limits our ability to ensure that the statute book in future is as coherent as it can be.

However, we want to alleviate any fears that we are taking powers which are not absolutely necessary in this Bill. As such we are prepared to take the significant step of removing the entire Henry VIII consequential powers in Clauses 5(3) and (4).

In addition, the Government have listened carefully to the concerns about the list of persons who can lawfully process data as a part of implementing new reciprocal healthcare arrangements under the Bill. To facilitate greater parliamentary scrutiny on this issue, the Government have tabled Amendment 20, which subjects any regulations that add to the list of persons authorised to process data for the purposes of the Bill to the draft affirmative procedure, which we have already debated. This would allow Parliament the opportunity to scrutinise authorised persons handling sensitive patient data, while equally ensuring that the Government can guarantee that future agreements are administered in the most efficient and effective way possible.

I hope that your Lordships will view these amendments, together with the other government amendments, as a genuine and significant effort to reduce the scope of powers in this Bill and respond to the concerns raised by this House concerning the use of Henry VIII powers. On that basis, I commend the amendments to the House.

[Lord Judge]

My Lords, I have already spoken warmly about the efforts by the noble Baroness, Lady Blackwood, and referred to us having a little touch of Blackwood in this House. Let it continue. I should like what has happened today to be habit-forming.

[Baroness Thornton]

I tabled an amendment in this group. First, I join the noble and learned Lords and all noble Lords in saying thank you very much to the Government and the noble Baroness for removing these Henry VIII powers, which cause so much heartache in this House—we really do not like them at all. I tabled Amendment 21 because I should like an explanation. Given that our Constitution Committee and the Delegated Powers Committee have several times said that they find the negative procedure rampant in the Bill, and that the British Medical Association has also voiced its concern about legislation being subject to the negative resolution procedure, in the interests of accountability, I need to ask the Minister to explain to the House the justification for negative procedure throughout the Bill. Should it not be subject to the same level of scrutiny as in the European Union (Withdrawal) Act, for example?

[Baroness Blackwood of North Oxford]

I thank the noble and learned Lords for their support for our amendments to Clause 5 and the removal of the Henry VIII operation within the Bill. I shall do my best to continue in the way I have started in this House.

I thank the noble Baroness, Lady Thornton, for her Amendments 21 and 23. The Government recognise that appropriate levels of scrutiny are the hallmark of an effective and responsible parliamentary system and that the processes by which we draft, consider and test legislation must be robust. It is necessary that we look at the nature of the subordinate legislation in the Bill and balance the need for scrutiny against the appropriate use of parliamentary time.

The draft affirmative resolution offers a greater level of parliamentary scrutiny and may be appropriate for particularly significant or sensitive regulations. For example, that is why the Government have agreed that that is appropriate when amending the list of authorised persons able to process data for the purposes of reciprocal healthcare. It is important to understand that, where the UK negotiates a new comprehensive international healthcare agreement, most of the important elements setting out its terms would be included in the agreement itself rather than in the regulations, made under the Bill, that implement it. The regulations giving effect to such an agreement would be much more likely to focus on the procedural, administrative or technical details, such as the types of documents or forms to be used to administer reciprocal healthcare arrangements. Evidence tabled during the course of the Bill’s passage from the Academy of Medical Royal Colleges and the British Medical Association demonstrates that the administration for current arrangements works well. The regulations made under this Bill would be likely to simply provide for the effective and efficient administration of these arrangements.

--- Later in debate ---

Moved by

[Baroness Blackwood of North Oxford]

19: Clause 5, page 3, line 43, after “law” insert “that is not primary legislation”

--- Later in debate ---

Moved by

[Baroness Blackwood of North Oxford]

20: Clause 5, page 3, line 45, leave out “this Act which amend, repeal or revoke primary legislation” and insert “section 4(6)”

[Baroness Blackwood of North Oxford]

I beg to move.

Amendment 21 (to Amendment 20)

Tabled by

--- Later in debate ---

Moved by

[Baroness Blackwood of North Oxford]

24: Clause 5, page 4, line 3, leave out “A” and insert “Any other”

Children: Oral Health

Baroness Blackwood of North Oxford Excerpts

Tuesday 12th March 2019 Lords Chamber

[Baroness Benjamin]

To ask Her Majesty’s Government what plans they have to tackle the oral health problems of hard to reach children, especially those in deprived areas of the country, through the Starting Well Core scheme.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, Starting Well Core allows commissioners, where they identify local need, to establish schemes similar to the National Starting Well scheme, which runs in 13 high-need areas. Starting Well Core has a particular focus on children up to two years old; practices engage with a wide range of partners to promote the importance of early preventive care. Areas that have so far introduced the approach include London, the West Midlands, Shropshire and Staffordshire, Cheshire and Merseyside, and Greater Manchester.

[Baroness Benjamin (LD)]

My Lords, too many five to 10 year-olds in deprived areas undergo general anaesthetic in hospitals to have their decayed teeth removed. Starting Well Core is therefore a welcome first step towards ensuring that children are seen by a dentist, preventing them from developing decay at a young age. Unfortunately, this scheme contains no educational element, only posters and leaflets available at dental practices, seen by those already attending. There are no measures to get the hard-to-reach children through the dentist’s doors. How do the Government plan to encourage all carers to take their children to the dentist, even before their first birthday? Will they please introduce supervised tooth brushing in nurseries and primary schools to combat this epidemic?

[Baroness Blackwood of North Oxford]

The noble Baroness asks some very important questions. I am pleased to say that 77% of five year-olds now have no visible decay, compared to 69% in 2008, which is a welcome reduction. We accept, however, that while these figures represent a significant improvement, there are unacceptable inequalities in children’s oral health. She is right that the Starting Well Core scheme is operating in areas of high need and the crucial issue is how children are sign-posted to these practices. Practices are using a mix of advertising, linking with other health professionals and actively engaging with local communities in schools and shopping centres and at local events. I hope that she is reassured by this answer.

[Baroness Hollins (CB)]

My Lords, there are greater unmet oral health needs for people with learning disabilities. These are issues that start in childhood and continue into adulthood. Does the Minister agree that the educational methods proposed for children should be adjusted to be suitable for children with learning disabilities and extended into adult life, as suggested by the Faculty of Dental Surgery? I welcome the new government guidance that was published last week on the oral health needs of children and adults with learning disabilities.

[Baroness Blackwood of North Oxford]

The noble Baroness makes a very important point about ensuring that dental care is available and accessible to all. Dental commissioning responsibilities are for NHS England, which is responsible for ensuring that dental services meet local needs and helping individuals who are unable to access a dentist. She has raised a very important point about access for those with learning disabilities and I shall ensure that this is raised within the department.

[Lord Colwyn (Con)]

My Lords, we will not reduce oral health inequalities if we do not ensure that every child is able to get their free NHS dental check-up. Dentists’ morale is so low that every week NHS dental practices are closing, leaving some patients facing a 90-mile round trip to find a dentist. A recent survey showed that three in five of all NHS dentists are planning to scale down or leave the NHS in the next five years. Government funding has fallen in real terms and we are waiting for the rollout of the new dental contract, work on which started eight years ago. Will my noble friend comment on these important changes? Programmes such as Starting Well Core will not able to help any children if there are no NHS dentists left to deliver them. I declare my usual interests, which include vice-presidency of the British Fluoridation Society.

[Baroness Blackwood of North Oxford]

I thank my noble friend for his question; he is of course very expert in this area. We want NHS dental services to be attractive for the profession and we remain committed to reforming the dental contract, which should help, but we recognise that there are a range of reasons for contracts being handed back, whether it is retirement, a decision to concentrate on private work or, in some cases, reorganisation of the companies providing the service. It is important that NHS England works with other local dentists to ensure that patients can continue to access dental care. There is a level of concern about recruitment and retention of dentists, and those difficulties need to be addressed by NHS England in its role as the commissioner. It is continuing to ensure that it works collaboratively with the profession and the department is keeping a close eye on this.

[Baroness Thornton (Lab)]

My Lords, tooth decay is a major source of health inequalities, as the noble Baroness has acknowledged, with 33% of the most deprived five year-olds having tooth decay, compared with 13.6% of the least deprived. In some parts of the country—the north-west, the West Midlands and Yorkshire—tooth decay rose for the first time in the last 10 years. How much investment will the Starting Well Core scheme have and for how long? When will we learn from the Government whether this has provided the right kind of remedial action for the most deprived children?

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her question. I shall write to her on the exact amount of investment, but there are some reassuring figures coming forward: 77% of all five year-olds now have no visible decay, compared to 69% in 2008; there has been a fall in the number of extractions per 100,000 finished consultant episodes for the first time in the last decade; and more children accessed dentistry over the last year. All this is reassuring and we are committed to improving access and equality of access to dental care—that is what the Children’s Oral Health Improvement Programme Board, led by PHE, is intended to do. It brings together 20 stakeholder organisations specifically focused on oral health. There is a significant amount of activity targeting exactly the issue the noble Baroness raises.

[Baroness Boycott (CB)]

My Lords, children get tooth decay because they eat too much sugar and too many sweets. How far are the Government getting with the commitments they made in chapter 2 of the obesity plan to restrict advertising of high-sugar products on TV before the watershed, and price and location promotions in supermarkets?

[Baroness Blackwood of North Oxford]

The noble Baroness is exactly right, in that improving children’s oral health is a wider picture: it is about not just access to dentistry but a preventive approach, which is a core government priority. This is exactly why we introduced the children’s obesity plan, one aspect of which is a consultation on advertising. Proposals on that will be brought forward shortly.

[Baroness Janke (LD)]

My Lords, what is the Government’s assessment of the number of children receiving dental care from Dentaid, a peripatetic charity that provides emergency care in third-world countries? Does she consider this an acceptable way of safeguarding children’s oral health, and what will she do about children’s lack of access to NHS dentists in many parts of the country?

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her question. I shall have to write to her about access via Dentaid, which I was not aware of; it is a very important point. We are committed to driving down inequality of access and are pleased that the number of young people accessing dentists has increased. One of the key measures in reducing inequality is the Starting Well Core programme, which has targeted areas of highest need, and its performance is encouraging. However, she is absolutely right: we must drive out inequality of access to children’s dentistry and the Government are committed to doing that.

General Food Law (Amendment etc.) (EU Exit) Regulations 2019

Baroness Blackwood of North Oxford Excerpts

Tuesday 12th March 2019 Lords Chamber

Moved by

[Baroness Blackwood of North Oxford]

That the draft Regulations laid before the House on 31 January be approved.

Relevant document: 17th Report from the Secondary Legislation Scrutiny Committee (Sub-Committee B). Considered in Grand Committee on 6 March.

Motions agreed.

European Qualifications (Pharmacists) (Amendment etc.) (EU Exit) Regulations (Northern Ireland) 2018

Baroness Blackwood of North Oxford Excerpts

Thursday 7th March 2019 Lords Chamber

Moved by

[Baroness Blackwood of North Oxford]

That the draft Regulations laid before the House on 6 December 2018 be approved.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, this statutory instrument has been brought forward in the absence of the Northern Ireland Assembly which, as noble Lords will be aware, is suspended. We have just debated a complementary instrument which deals with the recognition of other EEA and Swiss health and care qualifications in the UK in a no-deal scenario. My department has worked closely with Northern Ireland Civil Service officials in the development of these regulations and they are the result of positive and collaborative work between the respective departments. Noble Lords will now be familiar with the recognition arrangement for all other EEA and Swiss qualified health and care professionals across the UK, which this instrument seeks to replicate. I will therefore describe only briefly what these regulations do.

This instrument deals with the recognition of EEA and Swiss pharmacist qualifications in Northern Ireland. It has three main effects. First, like the previous set of regulations, it puts in place arrangements for the recognition of EEA and Swiss pharmacist qualifications that are currently automatically recognised. Secondly, it ensures that applications for recognition that are ongoing on exit day can be completed under the current legal arrangements. Finally, it removes a number of provisions which it is not possible or appropriate to maintain in the event of a no-deal Brexit.

The instrument puts in place new arrangements for the recognition of pharmacist qualifications that are currently automatically recognised by the Pharmaceutical Society of Northern Ireland. Such qualifications will become “relevant European qualifications”. As such, they will continue to be recognised without additional testing other than checks of language skills and whether there are concerns about their fitness to be registered.

The regulations give the PSNI a new power to stop the automatic recognition of a qualification by seeking designation of that qualification. This is not currently possible under the directive and is an important additional measure that will enhance public protection. Such a designation will be subject to the agreement of the Department of Health for Northern Ireland.

The Government have been asked whether they will set out guidance on the criteria to be applied by the PSNI when seeking the designation of a qualification. We do not intend to do so. The PSNI will be able to seek designation of any qualification that is currently automatically accepted about which they have concerns. It will be the PSNI’s responsibility to gather the evidence in support of designation. The most likely basis for designation will be that a qualification does not meet the standard of the equivalent Northern Ireland pharmacist qualification and therefore presents public safety concerns. The PSNI sets the standards for Northern Ireland pharmacist qualifications and is therefore best placed to identify if there is a case for designating a qualification as not being comparable to these standards. The arrangements for the continued recognition of automatic qualifications will be reviewed by the Secretary of State for Health and Social Care no later than two years after these regulations come into force.

Qualifications that are not covered by the automatic system are considered by the General Pharmaceutical Council, which regulates pharmacists in Great Britain. These pharmacists can practise in Northern Ireland under a memorandum of understanding between the GPhC and the PSNI. This arrangement will continue, and changes to the GPhC’s procedures in a no-deal exit have been dealt with in the previous order.

These regulations enable applications which have been made before exit day to be concluded under current arrangements as far as practically possible. The instrument also allows individuals practising under temporary and occasional status or under the European professional card to continue to do so until such registration expires. Concerns have been expressed that the removal of temporary and occasional registration will have a detrimental impact on the number of EEA and Swiss trained pharmacists practising in Northern Ireland. I do not accept this. The PSNI does not have any pharmacists registered to practise on a temporary and occasional basis and has never received an application for temporary and occasional registration in Northern Ireland.

The instrument removes obligations and administrative arrangements that no longer apply to the PSNI, operate effectively or are appropriate to maintain when the UK leaves the EU. These include the requirement to share information through the European Commission’s IMI, to which regulators will no longer have access; arrangements that allow pharmacists to practise in Northern Ireland using an EPC; and the requirement on the PSNI to set professional education and training standards that comply with standards set in the directive. This will provide the PSNI with greater flexibility to set education and training standards that meet the needs of the pharmacy profession in Northern Ireland.

These regulations put in place a system for the recognition of EEA and Swiss pharmacist qualifications in Northern Ireland if the UK exits the EU without a deal. They also ensure that applications in progress on exit day will be concluded under current arrangements as far as possible. The regulations ensure a consistent approach to the recognition of professional health and care qualifications across the UK.

[Baroness Thornton (Lab)]

My Lords, I thank the Minister for introducing these regulations. These ones are kind of like a double whammy: there are no-deal issues to deal with and no Assembly in Northern Ireland to deal with them.

These regulations are not as complex as the other ones. However, briefings we have received about this in the last week suggest there is some confusion among pharmacists in Northern Ireland about what might happen. The Company Chemists’ Association suggests that the impact of Brexit,

“could lead to a major nationwide shortage of pharmacists available for work”.

There has reportedly been a huge drop in the number of pharmacists registering with the General Pharmaceutical Council since the Brexit vote, with registrations of pharmacists from the EEA falling by 80%—that is generally, not just in Northern Ireland. The Chief Medical Officer for England stated that our pharmacists will be on the front line if there are any shortages. It makes being a pharmacist in the next month or so a pretty daunting prospect.

Concerns are rife, despite the Government stating that they wish to keep free movement of the protected professions and recognising pharmacists’ qualifications. Can the Minister clear up the confusion between pharmacists? Some seem to be saying it will be okay; others say they will fare very badly in the event of no deal. Can assurance be given to pharmacists that their qualifications will be recognised after we exit the European Union? Can the Minister outline the impact she thinks Brexit will have on our pharmaceutical industry and our chemists? In the UK, we depend on our pharmacists as the front line, the people we go to quite often so that we do not have to bother our GP. There seems to be a lot of concern out there that our pharmacists will find themselves in some difficulty.

[Lord Lea of Crondall (Lab)]

My Lords, I want to pick up a point made by both the Minister and my noble friend Lady Thornton at the start of her remarks—the lack of an Assembly and how things are dealt with in Northern Ireland. The Minister may not be able to respond to this, but I will put it on the record to see whether someone in government could respond. Is she aware of reports in the press that civil servants in Northern Ireland are increasingly worried about having to take policy decisions? The people then think they should be accountable for the policy decisions, so criticisms are made of civil servants who are making policy decisions. This is certainly not what anybody wanted, but it is inevitable now and has been going on for some time.

This is one of many examples. If there is no way in which the Northern Ireland political parties can be consulted, the way they are behaving is causing an increasingly treacherous situation. I say this to put it on the record and ask for someone in government to respond as to whether they agree that Northern Ireland’s civil servants are in an impossible position in terms of them making policy. Secondly, I ask whether consideration has been given to how far the Civil Service in Northern Ireland circulates this material to political parties and seeks any feedback. Is that also out, in the present situation of no Assembly?

[Baroness Blackwood of North Oxford]

That was quick. I thank noble Lords for their contributions. The points made by the noble Lord, Lord Lea, are indeed important and concerning. I will arrange for the specific points he has raised to be answered in writing. On the issues regarding this SI, I would like to reassure him that since August 2017 my department has engaged closely with the PSNI and colleagues in Northern Ireland in developing this instrument. These have been technical discussions relating to the proposed amendments to legislation and how they could impact the provision of healthcare services. The department has regularly communicated with stakeholders and colleagues in the devolved Administrations to ensure that their comments on the draft legislation were central to the development of the regulations. There were regular discussions between my officials and each health and care regulatory body to ensure that this reflected operational performance in country. I hope that reassures the noble Lord.

I move on to the questions raised by the noble Baroness, Lady Thornton. We do not have figures for pharmacist registration in Northern Ireland, so I will have to write to her on that. On the general point regarding the numbers of pharmacists and the role they play in Northern Ireland, she is absolutely right. The Government recognise the important contribution to Northern Ireland made by regulated pharmacists, including those from the EEA and Switzerland. That is exactly why we are bringing forward this instrument today, to maintain a simple procedure for recognising EEA and Swiss pharmacy qualifications to help ensure that EEA and Swiss trained pharmacists can be registered to practice in Northern Ireland after exit day should there be no deal, even though we do not want that to happen. It puts in place after exit day a system of recognition similar to the current system, which is why we think it is workable. It allows applications made before exit day to be concluded under current arrangements as far as possible, and allows individuals practising under temporary and occasional status or under the European professional card to continue to do so until such registration expires. For that reason, we think this should have no impact on the numbers of pharmacists operating in Northern Ireland.

I think I have answered the questions raised, and I hope that has reassured noble Lords. On that basis, I commend the regulations to the House.

Motion agreed.

European Qualifications (Health and Social Care Professions) (Amendment etc.) (EU Exit) Regulations 2018

Baroness Blackwood of North Oxford Excerpts

Thursday 7th March 2019 Lords Chamber

Moved by

[Baroness Blackwood of North Oxford]

That the draft Regulations laid before the House on 20 December 2018 be approved.

Relevant document: 12th Report from the Secondary Legislation Scrutiny Committee (Sub-Committee B)

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, the Government recognise the important contribution made by regulated health and care professionals, including those trained in the EEA and Switzerland. This statutory instrument ensures that professionals with EEA or Swiss qualifications have a clear route to seek recognition of their qualification when the UK leaves the EU.

Following the UK’s exit from the EU, directive and treaty rights under the Treaty on the Functioning of the European Union will no longer apply to the UK in the event of no deal, save to the extent that they have been introduced by UK domestic legislation. Parts of domestic legislation implementing the directive will not operate effectively after exit day and there would be no clearly lawful route for holders of EEA and Swiss health and care qualifications to be registered to practise in the UK. This instrument amends professional legislation in the UK to ensure that a system for the recognition of professional qualifications continues and that professionals with EEA and Swiss qualifications will have a clear and lawful route to seek recognition of their qualifications after exit day.

Arrangements for the recognition of professional qualifications within the EU are provided for by the directive on the recognition of professional qualifications. If UK domestic legislation is not amended, many of the directive’s provisions will still be part of UK law after exit day. However, they will not function properly and in some cases will be inoperable. For example, regulators may lose the ability to recognise certain EEA and Swiss qualifications. This would mean, as I have said, that health and care professionals who want to work in the UK will not be able to do so. Changes to domestic legislation, which implements the directive, are therefore needed to ensure that recognition of EEA and Swiss qualifications can continue in the unlikely event of a no-deal exit.

The UK has been a major beneficiary of the arrangements that European directives have put in place on this matter. Since 1997, more than 77,000 EEA and Swiss qualifications in the automatic professions of doctors, nurses, midwives, dentists and pharmacists have been recognised in the UK. By contrast, fewer than 7,000 UK qualifications have been recognised in the EEA and Switzerland. Directives have supported the recruitment of skilled professionals to the UK’s health and care sector, so it is important that arrangements are in place to allow for the continued registration of such professionals if the UK leaves the EU in a no-deal scenario.

This instrument deals with the recognition of EEA and Swiss professional qualifications in the UK. It has three main effects. First, it puts in place arrangements for the recognition of EEA and Swiss professional qualifications that are currently automatically recognised. Secondly, it ensures that applications for recognition that are ongoing at exit day can be completed under the current legal arrangements, as far as practically possible. Finally, it removes provisions that are not possible or desirable to maintain in the event of a no-deal Brexit.

I will take some time to set out exactly what the instrument does. It puts in place new arrangements for the recognition of EEA and Swiss professional qualifications that are currently automatically recognised by UK regulators. Such qualifications will become acceptable overseas qualifications. These qualifications will continue to be recognised without additional testing, other than checks on language skills and where there are concerns about applicants’ fitness to be registered. The regulations give UK regulators a new power to stop the automatic recognition of a qualification by seeking designation of that qualification if so desired. This is not currently possible under the directive, and this important additional measure will enhance public protection. Such a designation will be subject to Privy Council consent.

The Government have been asked whether they will set out in guidance the criteria to be applied by regulators when seeking designation of a qualification. We do not intend to do so. UK health and care professional regulators currently set the standards for UK qualifications. In our view, therefore, they are best placed to identify whether there is a case for designating a qualification as not comparable to these standards on the grounds of public safety. UK regulators will be able to seek designation of any qualification that is currently automatically accepted but about which they have concerns. It will be the responsibility of the regulators to present the evidence in support of designation. The most likely basis for designation will be that a qualification does not meet the standard of the equivalent UK professional qualification. The arrangements for the continued recognition of automatic qualifications will be reviewed by the Secretary of State for Health and Social Care two years after these regulations come into force.

These regulations also enable qualifications that are not currently covered by the automatic system to be considered by the relevant UK regulator and compared with the equivalent UK standard, as is currently the case. The regulations enable applications which have been made before exit day to be concluded under the current arrangements, as far as practically possible. This instrument also enables individuals practising under temporary and occasional status, or under the European professional card, to continue to do so until such registration expires.

Concerns have been expressed that the removal of temporary and occasional registration will have a detrimental impact on the number of EEA or Swiss-trained healthcare professionals practising in the UK, but we do not think that that is a genuine problem. Just 160 professionals are registered on a temporary and occasional basis. Professionals practising on such a basis will not lose their registration on exit day; they will instead be able to practise until their registration expires, which may be for up to 18 months. At that point they will be able to seek full registration in the same way as any other holder of an EEA or Swiss qualification.

Finally, this order removes obligations and administrative arrangements that will no longer apply to the UK regulators, operate effectively or be desirable to maintain when the UK leaves the EU. These include: the removal of the requirement to share information through the European Commission’s internal market information system, IMI, to which UK regulators would no longer have access; the ending of arrangements that allow professionals to practise in the UK using an EPC, which relies on having access to IMI; and the removal of the requirement on UK regulators to set professional education and training standards that comply with standards set in the directive. This provides UK regulators with greater flexibility to set education and training standards that meet the needs of the health and care sector in the UK.

These regulations put in place a system for the recognition of EEA and Swiss professional qualifications if the UK exits the EU without a deal. It also ensures that those applications that are in process on exit day will be concluded under the current arrangements, as far as practically possible. On that basis, I beg to move.

--- Later in debate ---

[Baroness Blackwood of North Oxford]

I thank your Lordships for what I think we can call a robust debate. I will start by discussing the designation criteria, which were at the core of the questions from the noble Baronesses, Lady Thornton, Lady Jolly and Lady Hayman, and the noble Lord, Lord Hunt, and are central to this SI. It is important to set out the differences between the current system and what future recognition might look like under the SI. Obviously, we understand that this would happen only in a no-deal scenario, which the Government very much wish to avoid.

To clarify, the current system is based on automatic recognition of EEA and Swiss qualifications, as listed in Annexe 5, with eligibility based primarily on an applicant’s nationality rather than where the qualification was gained. In future recognition, eligibility would be based solely on whether the individual holds a relevant EEA or Swiss qualification. UK regulators would therefore be able to apply for designation of an individual EEA/Swiss qualification as well. That is where the concept of flexibility comes from, which so upset my noble friend Lord Deben. Some aspects of the directive would no longer apply to the UK, so some of the ways in which the directive applied previously—such as on hours, which have previously been used to determine qualification—might no longer be appropriate in determining whether a qualification has been met.

This flexibility in setting standards should be welcomed. Indeed, we noted that Charlie Massey, the chief executive of the GMC, has previously raised concerns about the training of some individuals we had to accept under this automatic recognition process. For example, he raised concerns about family doctors in Italy before the Health and Social Care Select Committee. The General Dental Council has also raised concerns about the quality of some Romanian and Spanish dental qualifications. Under the new proposals, we would be able to raise such concerns through the designation process. They would go to the Privy Council because that is already the normal process through which UK regulators designate qualifications in the UK system. The process proposed under this SI is the standard UK process for establishing professional qualifications.

Moving on to how this would work, the instrument enhances the UK regulators’ powers to protect the public by designating as no longer acceptable EEA and Swiss professional qualifications that they are currently obliged to accept automatically. As I said, the grounds for designating a qualification will be determined by the UK regulator, which is best placed to make such decisions. The UK regulator will be able to seek designation of any individual professional qualification about which it has concerns. The most likely basis for such a designation will be that a qualification does not meet the standard of UK qualifications. We do not expect the approaches to designation to vary significantly between regulators as they have a shared objective of protecting, promoting and maintaining the health and safety of the public—and long experience of doing so. Therefore, the reasons for seeking designation and evidence supplied in support of designation are expected to be largely consistent. As I said, Privy Council consent must be given for a qualification to be designated. This standard system has been used previously.

The Government have been asked whether they will set out guidance on the criteria to be applied by regulators when seeking designation of a qualification. We do not intend to do so because we believe that the most likely basis for designation will be a qualification not meeting the standard of equivalent UK professional qualifications. We think that UK regulators, not the Government, are the authority on standards for healthcare professionals practising in the UK. They set the standards for UK health and care professional qualifications and are therefore best placed to understand if there is a case for designating a qualification. As I said, the Privy Council has a well-established role in overseeing the UK’s health and care professional regulators. For some regulators, including the GCC and GOsC, it approves UK qualifications and the appointment of council members. Its new role in approving applications for the designation of EEA qualifications is simply an extension of its existing role.

Costs and the impact assessment were referred to by a number of noble Lords but particularly exercised my noble friend Lord Deben. I am afraid that we have gone into the costs in some detail, despite the concerns he raised. He will know that UK regulators operate on a full-cost-recovery basis and set registration fees that meet the cost of processing applications. The cost to regulators of moving to the new system is considered negligible because it mirrors the current system, as far as possible, for at least two years—we intend to review that, once the regulations come into force. Should the regulator incur additional cost, it will be able to recoup it through fees. We estimate the total cost to regulators on the automatic system—including the NMC, the GMC, the GPhC and the GDC—to be £250,000 per year and an additional £60,000 for recruitment costs in the first year of these regulations coming into force. This could raise registration fees by an average of 27 pence per registrant per year for the regulators to recoup additional administration costs. We have costed the impact and believe the assessment to be reliable. That is why we have the GMC’s support; it believes that the impact assessment is reasonable and that it can cope with the impact.

I want to address concerns raised about temporary workers. I know that the noble Baroness, Lady Jolly, wanted to re-raise this even though I tried to address it in my opening speech, as the noble Baroness, Lady Thornton, acknowledged. As we said, we do not think that the removal of this group of registrations will cause concern as only 160 professionals are registered on a temporary and occasional basis. Professionals practising on such a basis, even in that small group, will not lose their registration on exit day; they will be able to practise until their registration expires, up to 18 months later. At that point, it will be open to them to seek full registration in the same way as any other holder of an EEA or Swiss qualification. It is important to note that the number of joiners from the EEA has remained steady at around 2,050 a year since 2016. In 2017-18, doctors joining the register from non-EEA and UK routes made up 32.4% of the total, while EEA applicants made up 16.2%. We are confident that the impact on that point will be manageable but we will keep a close eye on it and ensure that it is kept in check.

Moving on to the question about the IMI, raised by my noble friend Lord Deben and the noble Baroness, Lady Jolly, it is absolutely right that if the UK leaves the EU without a deal, we will no longer have access to EU systems, including the IMI system which gives us access to the exchange of information about healthcare professionals. The regulators are aware of this and they are preparing for it. It is important that this instrument will mean that they will not be required to put in place new procedures for the recognition of EEA qualifications and that any costs involved with the loss of the IMI system are unavoidable in the case of no deal. Such costs depend on a number of factors. While we would like to see continued access to the IMI system, it is worth bearing in mind that the registration of international health professionals takes place with non-EEA registrants without access to IMI. We have managed to ensure that that happens safely, effectively and efficiently. However, we will do our utmost to ensure that we consider other means to replace IMI that comply with the GDPR, such as standard contractual clauses. I hope that reassures noble Lords on that point.

Perhaps I may go on to answer the questions raised by the noble Lord, Lord Crisp, and the noble Baroness, Lady Jolly, on Spanish nurses and nurses from the Republic of Ireland. There is an issue on this point and I recognise the concerns that have been raised. There will be no change as a result of these regulations in the way Irish and Spanish qualifications are accepted, but at this point the Spanish regulator has said that it will not recognise the UK practice of Spanish nurses. This is a matter for the Spanish body, but we are continuing to discuss as a matter of urgency how EU regulators will recognise UK practice and qualifications, so that it does not matter which we are taking up.

As regards Ireland, the regulations ensure the continued recognition of Irish professional qualifications in Northern Ireland for at least two years after exit day and will allow professionals practising under temporary and occasional registration status to continue to do so until that registration expires. We are making sure that health and care practice across the island of Ireland is maintained smoothly and continuously. This has been a priority for the Government.

With those comments, I hope I have addressed the main concerns raised by noble Lords and given reassurance on those points. On that basis, I beg to move.

[Lord Warner]

My Lords, can the noble Baroness give me some answers to the points I raised about guidance being given in the event of no deal and exit on 29 March? First, how are the Government going to communicate that guidance to all the interested parties in the time available? Secondly, I asked about the status of these SIs in the event that the Article 50 period is extended beyond 29 March but there still being no deal. Does that mean that after that period, these SIs would come into effect when the period of exit is established post 29 March? Thirdly, what happens to these SIs if there is a deal? Does the present status carry on, with these SIs being put into limbo and therefore not introduced?

[Baroness Blackwood of North Oxford]

I apologise to the noble Lord for missing out on my answers to his questions; that was most remiss of me. These SIs come into force only if there is a no-deal exit. Should there be an extension of Article 50, they would not come into force until or if there is a no-deal exit, which is obviously most undesirable and something the Government are seeking to avoid.

On the communication of the effect or implementation of these SIs, they have been developed in close collaboration and consultation with the regulators that would be impacted. They are well informed about their operation, and given that the effect of the SIs is to continue with business as usual as far as possible, we hope that that is the de minimis effect. I shall write to the noble Lord in response to his final question, as I am afraid I have forgotten what it was.

[Baroness Thornton]

My Lords, I thank the Minister for her extensive response and noble Lords for their interventions and questions on this SI. The indignation and anger of the noble Lord, Lord Deben, has been reflected right across the House. Noble Lords may not express it quite as well as he has, but it absolutely is there. We have just spent an hour and 10 minutes debating this issue. Then there are all the hours of preparation, the cost of civil servants, the cost of our time and, indeed, the worry that all this is causing, not only to us in the Chamber but to millions of people outside. As the noble Lord, Lord Deben, and others have said, the Minister has done the best she can with the hand she has been dealt and answered our questions to the best of her ability. However, this is not where any of us wants to be. On that basis, I shall withdraw my amendment.