In Vitro Fertilisation: 40th Anniversary

Baroness Jolly Excerpts

Thursday 13th September 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I know it is customary when we begin to wind up to say, “This has been an excellent debate”, but this debate really has been. It has been excellent simply because we have all the expertise here among us—I certainly do not include myself in that at all. The tone was set by the contribution of the noble Baroness, Lady Deech, raising the outstanding issues of genetics regulation and new science. All this of course comes from her role as chair of the HFEA. She raised many more issues and it might be worth trying to tease some of them out, and perhaps have more detailed debates. We have all been painting with quite a broad brush today and some of the issues need a slightly more detailed camel-hair brush.

The noble and learned Lord, Lord Mackay of Clashfern, was there to ensure that the law was fit for purpose, and 300,000 children are really grateful that that happened. He spoke about the ground-breaking legislation but also the importance of his neutrality; I thought that was a really interesting history lesson. My noble friend Lady Barker spoke of surrogacy and reminded us all that families just do not look the same any more. The noble Baroness, Lady Boycott, painted—as a feminist—a lovely technicolour picture of offshore bank accounts, conception and contraception. I can remember being newly married as a young woman when all this was happening. It was quite amazing compared with what our mothers had had to go through; it seemed we could have choice every which way we looked.

I remember as well the sense of excitement and wonder at the arrival of Louise Brown, the world’s first test-tube baby. There were photographs of a beaming Steptoe and Edwards on the front pages, and clunky graphics by way of explanation. My noble friend Lady Barker and the noble Baroness, Lady Boycott, both mentioned Jean Purdy and I am going to talk about her too. The helpful Library briefing tells us that she was part of it at the first. A nurse by profession, Jean Purdy was the one who actually made what Steptoe and Edwards needed and wanted to do: she actually made it happen. She was not an add-on but absolutely part of the team, and seen by both of them as part of it. She was the one who saw the fertilised egg which was to become Louise Brown dividing to make cells. I cannot imagine how exciting that must have seemed at that time.

However, I do not recollect seeing Jean Purdy in any press coverage at the time. It appears, again, that she was wiped out of history by Oldham when a plaque was put up in 1982, and again by Bourn Hall—the centre which she, Steptoe and Edwards founded to deal with the huge call for IVF after Louise. To give credit where it was due, Edwards tried to remedy this and wrote letters to all the people concerned but he was not listened to. I sometimes get the feeling that some things never change.

There is absolutely no doubt that on the ethics of this birth, opinion was not restrained. Many, including religious leaders, wondered out loud whether we should be playing God. In response, the Government very sensibly appointed the eminently qualified academic Mary Warnock, later to become a Member of this House, to head up the Committee of Inquiry into Human Fertilisation and Embryology. Her report gave rise to the 1990 Act and its successors, which today still govern human fertility treatment and experimentation using human embryos. Its effect has been to require licensing for procedures such as in vitro fertilisation and to ban research using human embryos more than 14 days old. It has been really interesting to listen to the noble and learned Lord, Lord Mackay, explain where the 14 days came from, the need to balance faith and credibility and all the issues that were going on at the time.

Dame Suzi Leather—a name that I had forgotten about for a long time—former chair of the HFEA, noted that,

“perhaps the greatest achievement of the Warnock committee is that it managed to get an ethical consensus that people understood as well as shared”.

That is quite interesting. The report is worth a read—it is not hugely long—and if you look at who was sitting on her committee, you can see exactly what she meant. They included the usual: academics, medics and scientists, lawyers, the vice-president of the UK Immigrants Advisory Service, social workers, a theologian, the chair of a health authority, an expert in adoption and fostering and a former student counsellor of Cambridge University students. Evidence-givers were just as diverse. Again, they were the usual sort of suspects: churches and faith bodies, scientists, lawyers, health bodies, health practitioners, organisations dealing with fertility, gay rights organisations and, the one that really made me chuckle, Garter—the College of Arms gave evidence. I thought that was really interesting. Those of us who have been to talk to Garter will probably have a quiet smile at that thought.

Baroness Warnock said in her report, and in the letter that she wrote to the noble Lord, Lord Fowler, now the Lord Speaker:

“Despite the way in which members have worked together, there remain nonetheless certain differences between us; indeed, it would have been surprising if, on such sensitive issues, we had been united. These differences, presented in three formal expressions of dissent have, significantly, focused on the very subjects, surrogacy and research on human embryos, which, to judge from the evidence, arouse the greatest public anxiety. Thus even in our disagreement we have reflected the range of views within society. It is not possible that a report like this should be equally well received in all quarters, given some of the controversial issues we have had to consider. There is bound to be criticism that we have gone too far, or not far enough. However, we have sought to provide on the one hand a reasoned discussion of the issues which we hope will contribute to a high standard of public debate on matters which are of deep concern to the public, and on the other a coherent set of proposals for how public policy, rather than the individual conscience, should respond to a range of developments which many people will not wish to participate in, but which others find entirely acceptable. We have tried in short, to give due consideration both to public and to private morality”.


She writes well.

In 1985 the immediate response was to set up a licensing authority as an interim measure prior to the legislation, which was the Human Fertilisation and Embryology Act 1990. This happened when many of us were young and could readily identify with the importance and significance of these measures. Some 33 years later we have gene editing in research; mitochondrial donation; same-sex and unmarried couples treated just as married couples—as legal parents; the outlawing of sex selection; the removal of anonymity; and still more research continuing in hospitals, research establishments and universities. British scientists are nearly always at the cutting edge of this research. Here I agree with the points that were made by my noble friend Lady Barker and the noble Baroness, Lady Deech, about the critical importance of a strong regulatory framework and parliamentary scrutiny. However, the moral issues have not gone away. We dispute the difference between storing sperm for 55 years yet eggs for only 10. Is this an issue of equality or science? Then, there is the question of overdue legislation. Could the Minister tell us when and where this might be considered, and by whom?

Previous research has mainly focused on the economic issues that can affect assisted reproductive technology usage, such as a country’s wealth and health insurance costs. However, in 2017 scientists from the Oxford University department of sociology and Nuffield College assessed for the first time the relative importance of the role that economic, demographic and cultural normative factors play in the process. The study compares the prevalence of ART usage across 35 European countries since 2010—the number of ART cycles per million women of reproductive age, defined as 15 to 44 years. The findings reveal that although economic factors and national wealth are important, it is not merely affordability that determines ART use. ART treatments were more widely used in countries where it was considered culturally and morally acceptable to do so. For example, the Czech Republic, which ranks 51st in a poll of the world’s wealthiest countries, reported nearly 10,500 cycles per million women, a usage level almost identical to the comparatively wealthier Denmark. By contrast, high-income nations such as Italy and the UK reported only around 5,000 cycles per million, half the rate of the Czech Republic. I am not sure what that tells us, but it is interesting that it is not just about the ability to pay.

We cannot have this debate without discussing the availability of IVF on the NHS, an issue already raised by the noble Baroness, Lady Boycott, and the noble and right reverend Lord, Lord Harries of Pentregarth. The 211 CCGs in England should be offering three cycles to women who meet the criteria based on evidence. In 2013, 24% of CCGs met that recommendation; now, it is nearer 12%—halving in five years. That is one in eight CCGs. I know that choices are difficult for a commissioner, but the consequences can be heartbreaking for a couple wanting a family. CCGs in Bury, Heywood, Middleton and Rochdale, Oldham and Tameside and Glossop all offer three cycles, as per guidance. I like to think that Oldham is aware of its history in making that decision. CCGs in Cambridge, Croydon and Basildon do not offer IVF at all.

Are the local health and well-being boards involved? Could the Minister clarify what public engagement and consultation goes on when making those difficult commissioning decisions? What support or counselling is given to couples, many of whom may be grief stricken or distraught? Is IVF only possible for affluent couples? Is a baby something that all families should consider as a right and therefore available on the NHS? These are questions that, hitherto, we have been sufficiently wealthy as a nation not to need to answer, but we do now.

Perhaps, then, the 40th anniversary of Louise Brown, the first test-tube baby, should be an opportunity to consider these questions again.

Mental Capacity (Amendment) Bill [HL]

Baroness Jolly Excerpts

Committee: 1st sitting (Hansard): House of Lords
Wednesday 5th September 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I will resist the temptation to rerun Second Reading, but I thank all the organisations which have provided us with informative briefings as well as all the individuals, academics and carers who have done so—you all know who you are.

This rather ugly Gorgon of a Bill matters. It matters to those who are vulnerable and will unknowingly place their future in its hands. It matters to diligent professionals from both the NHS and care services. They do not know it, but it matters to the general population, too—many will become carers one day.

I wish someone had had the courage to tear it up and write a Bill that was clear, compassionate and contemporary—but they did not. Because we care we will spend the next few days in Committee and beyond, trying to make it fit for purpose. The noble Lord, Lord Hunt of Kings Heath, has given us the briefing around which we shape this debate on Clause 1 stand part and for which I thank the Relatives & Residents Association. It covers the role of the care manager, the centrality of the cared-for person and their views, best interests and advanced wishes; an understanding of what deprivation of liberty is, access to information and, indeed, cost.

It is worth mentioning that there are amendments from all over the House that cover each of these areas. Like others, I am concerned about the role of the care manager as assessor. Over the last few years I have met many kind, efficient care managers, both professionally and in my role as a carer. As professionals, they run hotel services, ensure that care needs are met and rosters are filled and deal with people who lack capacity with compassion. But experts in mental capacity they are not and I am concerned that they are given such a key role in this Bill. As chair of a not-for-profit organisation that cares for people with learning disabilities in residential settings, I know how hard it is to do this on the money that local authorities give us.

An efficient home is a full home. The person who determines whether someone should enter that setting or go somewhere else should, under no circumstances, be the manager. The conflicts of interest, no matter what checks and balances are in place, will always be there and that is the same for the private sector, not-for-profit and even, where it still exists—and I believe it does in parts—the public sector. Training and awareness should minimise this but we must be on our guard.

Everyone accepts that the 2005 Act has become not really fit for purpose and that this is a patching exercise. Everyone accepts that DoLS has run its course. Many believe that what we are trying to amend is drafted to save costs and that goes back to the briefing that this debate is based on—people live longer, care costs increase and these processes are not cheap. Can the Minister confirm that these amendments are all drafted to be the most effective way to deliver a better service and not as a cost-cutting exercise?

The noble Lord, Lord Hunt of Kings Heath, mentioned consultation, which is something that we on these Benches are concerned about. My understanding is that consultation did go on but it was with individuals grouped together—they were like focus groups of care home managers, social workers and so on. There was no consultation of the organisations, the umbrella bodies. I phoned many organisations before putting my thoughts together and tabling my amendments. All of them came back to say that they are going to see the department this week or next week but that they have not spoken yet. I think that is disappointing.

Much as there might be a temptation to scupper this Bill by supporting Clause 1 stand part, I know that it is for now the only alternative. I will do that in the hope that the Minister tells his right honourable friend the Secretary of State for Health and Social Care that it is barely good enough and that future patching of legislation is not acceptable. The people we are discussing really deserve better.

[Baroness Murphy]

My Lords, I support the noble Lord, Lord Hunt, in his endeavour to raise this important issue about care homes. I know we will return to it. This is a very good example of where I had not really thought about the twin-track approach to raising the safeguarding issue. I understand completely how this came about as an attempt to try to improve on the monstrous bureaucracy of DoLS. This is a very good example of that, to which I think the noble Baroness, Lady Jolly, alluded. We have a monstrous Bill at the moment. I remember discussions at the Law Commission with the Royal College of Psychiatrists as to how we might make it more streamlined and reduce costs, which in my view is pretty crucial if we are to target the right people. That led to the production of a process to involve care home managers which, on the face of it, looked as though it would cut bureaucracy.

--- Later in debate ---

I was told that I could not put a new principle into the Mental Capacity Act—that this was not the Bill to do it—so I am going to leave it at that point and just say that I tabled this amendment and it was slipped into this group. I am not expecting anybody to support it, but I hope that I will gather some support for restricting the criteria for the definition of a deprivation of liberty, in order that we can make the Bill fully workable and manageable for the people who really need it. In a perfect world, it would not be necessary. If we had loads of money, and thousands of assessors, legal experts and social workers involved, we might do it. Under our current and likely future resources, we cannot do it, so we should do the best we can with the resources we have and concentrate them on trying to improve the care of people who really need it. I beg to move.

[Baroness Jolly]

My Lords, there is always a risk in your Lordships’ House when an amateur follows a professional. I feel that I have a bit of a starter-for-10 moment as well, because both the noble Baroness, Lady Murphy, and I tabled similar amendments, Amendments 4 and 5, to achieve the same sort of aim. I could take noble Lords through my arguments, which again are similar to hers, but time is of the essence, so it might be worth putting both of them before the Minister to ask whether the Government would consider bringing back an amendment that would put a clear definition of deprivation of liberty in the Bill. There has been a lot of pressure from various parts of the sector for this to happen. At the moment, only case law gives an indication of deprivation of liberty, so to have something in the Bill would be helpful.

[Baroness Finlay of Llandaff]

My Lords, I have an amendment in this group that does not sit terribly well with the first two—but so be it. I will be brief. These attempts to define a deprivation of liberty are nobly submitted, but I worry about potential unintended consequences from the wording. I will not go through them in detail, but I hope that the Minister will assure us that this is something we can take away and look at. One difficulty is that one person’s imprisonment—a deprivation of liberty—might not be a deprivation of liberty to another, so this may be very personal in some aspects.

On Amendment 81 in relation to a “vital act”, I hope that the noble Baroness, Lady Murphy, will take reassurance from me—I do not know whether the Minister will agree with this or not—that anything done must be in a person’s best interest. Part of that is that it is a benefit and not a burden—or it may be a burden, but the benefits outweigh the burden. That has to be a fundamental principle in clinical decision-making.

The reason I tabled Amendment 82, which relates to an urgent authorisation, is that, looking through, I was concerned about unintended consequences from the way the legislation was written. I could see two, possibly—but they may be misplaced anxieties. First, in a true emergency situation, as a consultant in emergency medicine said to me, you just get on and do what you have to do. You do not go and look at paperwork. So, in an emergency situation, you may have to restrict somebody’s liberty to do what you have to do, which is in their best interest. You do not do something that is not in their best interest—and the last thing we want to do is impose any more bureaucracy or paperwork.

So I suggest that, possibly in the code of practice and not in the Bill, it should be clear that an urgent authorisation is an authorisation to begin longer-term care, but in an acute situation, in a clinical decision, nobody would expect people to even begin this process until we get to about 48 hours. I say that because a clinical decisions unit will normally have people staying in it for under 24 hours, as they may even on an acute medical ward, before being moved to a longer-term in-patient unit where their longer-term care may be assessed. Of course, we have people who have a transiently impaired capacity because of illness and the treatment of that will restore their capacity, such as the diabetic whose diabetes is out of control through either hyperglycaemia or hypoglycaemia, and things such as hypocalcaemia as well. None of those should be included.

The concern at the other end was that an urgent authorisation could be used for example to take a confused person with advanced dementia where care at home had completely collapsed. Possibly their main carer at home had suddenly been admitted to hospital. They would then have to be moved into a nursing home placement at great speed, but that may not be what they want and they cannot consent to it. They would have to be moved to that place, be in a placement and be assessed there. There needs to be some time limit so that this cannot linger on for months or years, with somebody saying, “Oh, well, they are here under an urgent authorisation”, rather than a longer-term authorisation. That is why I tabled the amendment. I accept that it is not perfect, but I hope it is something we can look at. It may be that the code of practice can clarify those issues.

General Practitioners: Indemnity Scheme

Baroness Jolly Excerpts

Monday 16th July 2018 Lords Chamber

[Lord O’Shaughnessy]

I agree with the noble Baroness’s final point. Indeed, one reason for sorting out this scheme is that we know it is a barrier to people joining the profession and, unfortunately, encourages them to leave it. There is of course an urgency, but nevertheless it is a complex discussion with commercial partners. I can tell her that we are talking to GPs themselves and their representative organisations to make sure they understand what is at stake, what we intend to do and that we intend to introduce the new scheme in April.

[Baroness Jolly (LD)]

My Lords, on 1 June, a DHSC spokesperson said:

“We are continuing to work closely with key stakeholders in the development of the scheme from April 2019”—


as the Minister said. The spokesperson went on:

“We will provide a further update in the near future”.


GPs need reassurance that this will not be kicked into the long grass. What is the department’s understanding of the “near future”—is it six weeks, six months or a year?

[Lord O’Shaughnessy]

That is a very existential question. The point is that we need to introduce the scheme by April and are absolutely committed to that. There are some very big decisions to be made on the scheme design now. We have a new Secretary of State who is getting up to speed on these issues as we speak. Our intention is to make those decisions to confirm the design of the scheme and to be able to tell GPs and other stakeholders publicly as soon as possible. We are committed to the April 2019 deadline.

Mental Capacity (Amendment) Bill [HL]

Baroness Jolly Excerpts

2nd reading (Hansard - continued): House of Lords
Monday 16th July 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, this has been an interesting and hugely well-informed Second Reading of the Bill and I join other noble Lords in welcoming the noble Baroness, Lady Barran, to her place. I am sure that she will bring a new and welcome voice to the House on all issues. My noble friend Lady Barker gave us a helpful account—a history lesson, if you like—which put everything into context. It is worth saying to the Minister now that it is absolutely not the case that we all sat around a table and decided what needed to be said. We have come to our views all on our own, and if we are saying much the same things, it is because they need to be said and are true.

I, too, welcome the Bill. It aims to make the process of depriving a vulnerable individual of their liberty simpler and less bureaucratic. Everyone here would agree that society is judged on how it manages its members who are vulnerable and unable to speak for themselves. This Bill makes a fair attempt at this, but it is not the finished article and I would probably give it a C. The points I will make fall into two distinct categories: points concerning the process of the creation of the impact of the Bill once it is enacted, and the second concerning the legislation itself: what should be in it, what should be taken out, and which clauses could be better worded.

The people who will be affected by this Bill are likely to be old, have mental health problems, autism or a learning disability, or have more than one of these conditions. I should refer to my interests as set out in the register. I chair a learning disability trust caring for more than 2,000 people, many of whom in our care lack capacity. I thank all of those who have provided us with briefings, and it is clear that common themes came out of them. One was the issue of finance. There was a feeling that this is going to be an expensive exercise. There will be a need to train assessors in care homes, to which I shall return later, to train advocates and, of course, to train the trainers. All of this will need to be rolled across England and Wales. Will care providers have to fund this, or will one-off training grants be made available? Certainly the system is under so much stress at the moment that it is unlikely to have the slack in budgets for extra training.

Then there is the role of care home managers. For some this might seem fine and a natural extension of their role. For others it may go into completely new territory where they have no experience and no confidence. I am sure that the Minister appreciates that most people with a learning disability no longer live in a care home but with carers in a domestic supported living setting. It would be a very large ask for those carers to assess the mental capacity of the person they support. Most carers are on the national living wage and may not be professionally ready to make such assessments.

Can the Minister clarify where the AMCP—approved mental capacity practitioner—sits in the new system and from where their funding comes? Where liberty protection safeguards are put in place, could an affected individual have an appeal funded? Will legal aid be available? Will the Minister explain why best interests are not included and what has taken their place? At the useful briefing last week, I inquired about consultation. For a Bill of such importance and with such a potentially huge impact, can the Minister clarify what consultation there was with provider organisations in the sector, the LGA, ADASS and the public at large? Over the last few months, many of us have had really interesting conversations with Sir Simon Wessely about his work reviewing the Mental Health Act. We welcome that review, but would it not have made sense to have waited until Sir Simon finished his work and then have a single view of the issue?

The Bill did not start from cold: the House of Lords Select Committee reported in 2014 on its scrutiny of the Mental Capacity Act 2005. Many noble Lords speaking today took part in those committee sittings. There was also the Law Commission’s Mental Capacity and Deprivation of Liberty report of 2017. They both made many fine recommendations and, along with many in the sector, I am surprised that a lot of work will need to be done in the summer to make the Bill finally fit for purpose. Among the areas I will be looking at in Committee is the issue of 16 and 17 year-olds. To include them in the legislation would align with the Mental Capacity Act. Can the Minister tell the House the rationale for not putting this transitional cohort in the Bill?

Article 5(1) of the European Convention on Human Rights uses the phrase “unsound mind”. The same paragraph also talks about vagrants. It was first drafted in 1950, nearly 70 years ago. It is not used professionally now and the profession believes that it has no place in a piece of modernising legislation; it creates unease among individuals, advocates and the sector alike. Article 5(2) calls for a detainee to be informed of the reason they are to be deprived of their liberty. Rather than having to refer elsewhere, how much more straightforward would it be to have this in the Bill? I support my noble friend Lady Barker’s view that any part of the Bill referring to the ECHR should spell out the impacts rather than cross-reference the Brexit debate.

Although not part of the legislation, the code of practice, once enacted, will make the Bill workable. Will the Minister clarify what progress has been made on writing a draft? Can noble Lords have sight of it? If so, when? This is a complex and important piece of legislation; I hope that the Minister is not expecting to complete it with just one day in Committee. We need to produce an A-plus Bill to send to the Commons. It may take more time than the Government want, but all the people affected by the Bill deserve better.

The NHS

Baroness Jolly Excerpts

Thursday 5th July 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I join other noble Lords in thanking the noble Lord, Lord Darzi, for tabling this timely debate and for his excellent speech in kicking it off. It is one of those speeches that we will want to reread, and we will need to pick up a copy of Hansard on Monday.

These Benches are proud that on this day 70 years ago the Leader in your Lordships’ House was Lord Beveridge, author of the report implemented by the Attlee Government, thus creating the NHS and social care entitlement. So perhaps this is true co-production.

I start by noting the contribution to today’s NHS of all the staff who over the last 70 years have worked tirelessly, whether as clinicians, carers, cleaners or managers, and I pay tribute to the current employees too. But what would somebody from 1948 make of the NHS now? My father-in-law graduated from Leeds medical school in that year and was one of the first cohort of NHS doctors—and very proud he was too. He recalled that there was a handful of drugs that they could prescribe, and after their six years’ training they knew pretty well all the medicines that there were to know. Later, he ran a GP practice from his home. One room became the waiting room and another the surgery. The family recall syringes being sterilised on the kitchen stove. He and a partner set up a practice which grew and grew, and it still exists. Today, I think he would be delighted to see his practice offer patients the ability to book appointments online and order repeat prescriptions, but he might be rather bemused by the need for a practice Facebook page.

Today, the life expectancy for men is 77 and for women 81. Then, it was 66 and 71. I think several of us have been looking at different briefings with different numbers, but the numbers are in the right sort of order. No one quite appreciated the impact of the impending baby boom rippling through the population. Most of the residents in today’s care homes were born before the NHS came into existence, and unless we mend our lifestyles a large proportion of us will not live as long as our parents.

In the new NHS, public health and prevention was important. I remember queuing in the village hall for cod liver oil, orange juice and polio jabs, and once at school we had nit inspections, eye and hearing tests, and TB jabs. Public health looks very different today—gone are the nit inspections—but local authorities have public health responsibility all over again. They look at health as a determinant in housing, social care and wider community services.

Prior to the NHS, the first port of call often was the high-street chemist for a chat with the pharmacist, who would be able to recommend the right remedy. This conversation was free, and a visit to the GP was out of reach for many. Now, too many of us visit our GPs expecting a prescription when we have a cough, cold or sore throat. We are unaware that we can get better with the help and advice of the pharmacist. If this was to be adopted as the first port of call by us all, our GPs would have time to deal with the people who are really poorly.

There cannot be a sustainable NHS without sustainable adult social care. Adequately funding social care would deliver benefits for local communities and savings for the public purse. For example, funding an expansion in social care capacity would alleviate NHS pressures and therefore enable more people to be discharged quickly and safely from hospital. We all have friends and relatives who, whether due to age, ill health or dementia, have found themselves in need of social care. The continued underfunding of social care affects us all. It is making it increasingly challenging for local authorities to fulfil their legal duties under the Care Act, leaving the ambitions of some aspects of the legislation at risk. Equally concerning is that, by 2025, another 350,000 people will need high levels of social care from councils. As the ADASS budget survey highlights, moving towards prevention and early intervention is one of the most important savings areas identified by councils. However, as budgets reduce, it becomes harder for councils to manage the tension between prioritising statutory duties towards those with the greatest needs and investing in services that will prevent and reduce future needs.

The current move towards integrated care organisations is welcome, but success will depend on strong leadership and a willingness of both health and care to co-operate, to share a budget and to involve patients, those in care and carers, and the voluntary sector in system design. As mentioned by the noble Baroness, Lady Morris of Bolton, the initiative currently under way in Greater Manchester, where 10 councils came together to deliver health and care services locally, has much potential. We await evidence of success and impact on the health community. In Cornwall, my part of the world, for the last year or so the local council has been working closely with the CCG to achieve the same end but on a much smaller scale and in a rural setting. However, where any services are devolved, we are also clear that national standards need to remain and that accountability will be key. As a quick note to the noble Baroness, Lady Gardner of Parkes, Cornwall still has all its community hospitals and they are used as step-up and step-down units. The challenge posed by the increased localisation of services is the risk of a postcode lottery in both availability and standards. Those local councils where there was the greatest need have low-rated housing, and any dividend from raising council tax is not enough to plug a gap.

Almost two years ago now, my right honourable friend Norman Lamb commissioned a group of experts from within the sector to look at the vexed issue of funding the NHS and social care. Among the recommendations were an annual rise in real-terms funding for the NHS in England in line with long-term growth. For the next five years, we believe that a 2% rise per year is a realistic figure. This should be matched by equivalent increases in funding for the devolved nations under the Barnett formula. A further recommendation was to set up an independent OBR for health to make recommendations to government about the funding required for a three-year cycle.

Recently, the noble Lord, Lord Patel, who sadly is not in his place, chaired a Select Committee of the House on the long-term sustainability of the NHS and adult social care. This was a look at the current system by a group of Peers with long experience of working in the NHS, government and social care. Their report was full of positive recommendations—it read like a critical friend’s review of an organisation in need of change. It took the Government some time to bring it to the House for debate; let us hope it takes less time to implement some of the recommendations.

Artificial intelligence, biosimilars, genomic medicine and robotic surgery would have been unimaginable to those doctors in 1948, but who knows what the next 70 years will bring. In many areas, we are on the cusp of system failure yet, in others, of huge system innovation. Organisations needing support should be encouraged, not punished. The Government need to be bold in their decisions and announcements in November. The Green Paper on social Care and its funding should be person-centred, encourage creative solutions and provide the necessary funding to deliver appropriate support for the NHS and for its stable future.

Health: Endoscopy and Bowel Cancer

Baroness Jolly Excerpts

Monday 2nd July 2018 Lords Chamber

[Lord O'Shaughnessy]

My noble friend is quite right to point out the potential of digital, particularly the analytical capability of artificial intelligence to look at samples. That was one reason why the Prime Minister recently pledged to have 50,000 more early cancer diagnoses by 2033—a long-term goal—precisely because the NHS is such a good place to use artificial intelligence to improve care.

[Baroness Jolly (LD)]

My Lords, after a cancer diagnosis, English patients have poorer outcomes than all but one of our European comparators. We welcome the announcement that the Minister has just made about new clinicians, but in some areas there are delays in referral, testing diagnosis and then treatment. The longest wait for treatment reported this year was 541 days. That is not good enough. How long does the Minister think we will have to wait for there to be sufficient clinicians and facilities to deliver a service that moves us significantly up the table?

[Lord O'Shaughnessy]

The noble Baroness is right to highlight the importance of waiting times. The 62-day standard is unfortunately not being hit at the moment. The NHS has pledged to get back on that standard this year. We are also piloting a faster, 28-day diagnosis standard in five areas at the moment with the idea of rolling that out so that there is a higher standard of care and fewer people have to wait longer.

Nursing and Midwifery (Amendment) Order 2018

Baroness Jolly Excerpts

Monday 25th June 2018 Lords Chamber

[The Earl of Listowel (CB)]

My Lords, the noble Baroness, Lady Thornton, and the noble Lord, Lord Willis, asked about the impact of this new profession on the wider healthcare workforce. I wonder whether it is helpful to ask the Minister at this point a little about possible impact, if any, on health visitors. There is real concern about the decline of health visitors; they had a resurgence in recent years but are in serious decline now. I do not wish to detain the House for too long if this seems a bit beyond the main business.

I am a patron of the charity Best Beginnings, which provides mental health and perinatal support for parents. I spoke with the chief executive last week. We recognise that health visitors are very important, as healthcare professionals working in the vital perinatal period to ensure the best attachment between parent and child. I recently spoke with the president of the Institute of Health Visiting, Dr Cheryll Adams. Again, she expressed concern about the decline of the number of health visitors. As we establish a new healthcare profession, do we not need also to think about this other, declining profession under the healthcare umbrella?

I imagine that there is no plan to replace health visitors with these new healthcare professionals, but sometimes there is a misunderstanding that health visitors are just there to weigh the baby, when anyone could do that. In fact, when family-nurse partnerships were introduced to support vulnerable parents, the outcome was significantly better when higher qualified practitioners worked with the families. This job is challenging, because people are often working with vulnerable families in poor housing and poor conditions. It is a demoralising profession, unless one has a good professional foundation.

I emphasis the importance of the vital early years. As Graham Allen and Mr Field MP have established, the first 2,000 days in a child’s life are the most important. We need to ensure that the best professionals are available to them. Two or three years ago, health visitor funding went from the Department of Health to local authorities. We all know that local authorities have very little money to spend, so it is not surprising that there has been a significant decline in the number of health visitors. Does the Minister recognise concerns about that decline? Will he assure the House that he is keeping in mind the health visiting profession and what can be done to sustain it and ensure its continued health?

I have a final question. This particular new brand of healthcare professional gives rise to the problem of professionals from the developing world being pulled in to fill the niche. I am sure that the Minister can assure us that we will not poach healthcare professionals from Nigeria, Ghana and elsewhere, but the possible risk of that certainly comes to my mind. I welcome the order and I look forward to the Minister’s response.

[Baroness Jolly (LD)]

My Lords, my contribution will be very short, as noble Lords have already said everything. We, too, welcome the role of the nursing associate. I commend the work of my noble friend Lord Willis of Knaresborough in making this happen and say to him that he can have the Front Bench if he is happy to take all that goes with it.

The noble Earl, Lord Listowel, made the point about impact. I just make one extra point. In remote locations—I live in Cornwall, but this could account for anywhere far-flung where there are hospitals and health establishments—there will be uptake from healthcare assistants who feel that they cannot leave home to train as a nurse because the distance is too great and they have family responsibilities or other commitments, but they could manage the two-year course. That would be really positive. Nursing associates would then improve in those establishments the quality, but also the skill mix, of nursing teams in areas where it is also particularly difficult to appoint.

I understand the timing of this SI. The noble Lord, Lord Clark of Windermere, said that perhaps there was still stuff to look at. It is really important that it gets on to the statute book, because we will have real live trainee nursing associates who need to register next year. Sadly, we cannot take any more time to do this, but from these Benches we really welcome the role of the nursing associate and the help it will give the NHS.

[Lord O’Shaughnessy]

My Lords, I sincerely thank every noble Lord who has spoken in the debate and engaged with these regulations so thoroughly. It has been a really important discussion about not just the new role of nursing associate but its impact on the overall health and care workforce. I am very grateful to all corners of the House for the broad welcome, albeit with questions and conditions, for the creation of this role.

I want to deal up front with the urgency of these regulations. I agree that there has been an element of rush, and I think we are all agreed on the requirement for it. But like all overnight successes, this has been a long time brewing, as the noble Lord, Lord Willis, pointed out. A lot of work has been done, and I salute, along with all noble Lords, the many people at the RCN, the NMC and others who have contributed to this, and the many people behind the scenes. It is quite right to acknowledge them. No doubt there is more work to come.

The primary debate, or part of it, revolved around the distinction between the nurse role and the nursing associate role. It is very important to be clear, as I hope I was in my speaking note, that these are distinct professions. They may all be part of the same family—there is a certain amount of semantics involved here—but they are distinct professions, which will be regulated distinctly, albeit in a joined-up way through the same regulator, which is quite right. The NMC is currently consulting on standards of proficiency. The department, with all the necessary arm’s-length bodies and others, will develop guidance for that separate profession. While nursing associates can inevitably support nurses, doctors and others, they will not just be the handmaidens to others, in the evocative phrase of the noble Lord, Lord Clark. They will be professionals in their own right.

It is also worth pointing out that, in the consultation going on at the moment on standards and proficiency, the NMC is also looking at the code of conduct and amendments to it. That consultation ends on 2 July so, again, I warmly encourage all noble Lords to contribute to that, because some of the ideas set out today could have an important role in getting that right.

The noble Baroness, Lady Thornton, asked about the financial risks involved in setting up the courses—making sure that they are properly constituted and so on. My department has a memorandum of understanding in place with the NMC to keep the costs of the set-up within agreed cost parameters. The costs of accrediting nursing associate courses are met from the annual registration fees paid by the NMC’s registrants. Therefore, the financial modelling has been investigated and we understand what we need to stick to.

Childhood Obesity Strategy

Baroness Jolly Excerpts

Monday 25th June 2018 Lords Chamber

[Lord O'Shaughnessy]

An upgrade in our grade is, I suppose, something to be welcomed. The noble Baroness is being a little unfair. The last obesity plan probably went beyond that of almost any country in the world, and this one certainly goes well beyond that. We know that we need to do more—that much is obvious from the facts—because, unfortunately, obesity continues to rise. We have taken big action through the soft drinks levy, improvements in reformulation and so on but it has not gone as far as we want. So we recognise the need to do more.

The noble Baroness referred to consultations but, if anything, you can accuse this paper of being too honest because any action requires consultation to go forward. I would not want her to be distracted by that because within it are some hard commitments. There is a commitment to voluntarism if we can make it work but, equally throughout, there is a commitment to legislate if that does not produce the right outcomes.

The noble Baroness asked about milk products. Again, if voluntary reformulation does not work, these will be considered by the Treasury as being liable for the levy on soft drinks to bring down the sugar content.

On advertising, the idea that we should have a 9 pm watershed across broadcasting is truly radical, and it is only right that we consult properly. There is a desire to do that by the end of this year, so the noble Baroness cannot accuse us of not moving quickly enough.

The Obesity Health Alliance, which counts dozens of bodies among its membership, has welcomed the plan set out today. Of course it wants us to get a move on—and we will—but it is important to note the radical change in policy to try to deal with this epidemic that we all face.

[Baroness Jolly (LD)]

My Lords, I thank the Minister for repeating the Answer to the UQ. Anything is welcome and I am at the stage where more questions are being raised than answered. A debate in this House would be useful and perhaps put some flesh on the bones. That is absolutely the wrong thing to say, but the House knows what I mean. It would give more clarity.

I wish to push the Minister a little further on the advertising issue. I appreciate that a consultation is coming up. We welcome the idea of using the watershed, but I am not clear from the Statement or from chapter 2 whether it includes all programmes before 9 pm or only programmes that are aimed at young people before 9 pm. That is an important distinction and it will be useful to know what is going to be consulted upon.

Families were mentioned in passing. I would like to know what work is to be done with families. I appreciate that there is not in this land a typical family, but we are trying to take out 500 calories a day from people’s diets and we need to point out the high calorific value not only of chips, which may seem obvious, but of pasta, rice—which everyone thinks is healthy—bread and buttered mash. There is still work to be done with families to make them understand quite what they are putting on their children’s table which seems healthy and fine.

Childhood Obesity: Yoga

Baroness Jolly Excerpts

Thursday 21st June 2018 Lords Chamber

[Lord O’Shaughnessy]

I will bring my mat.

[Baroness Jolly (LD)]

My Lords, as the Minister said, there really should be an evidence base before we pursue this too far. Does the department know whether there are sufficient teachers trained to teach children in yoga? Would there need to be appropriate safeguarding?

[Lord O’Shaughnessy]

I am afraid I do not know whether we know that. I suspect we do not. Yoga is an incredibly popular pastime for children and adults. Indeed, I think there are mother-and-baby yoga classes, which are also popular. I am sure safeguarding concerns will always be foremost when dealing with young children.

National Health Service: Assaults on Staff

Baroness Jolly Excerpts

Wednesday 20th June 2018 Lords Chamber

[Lord O’Shaughnessy]

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

[Baroness Jolly (LD)]

My Lords, in England around 200 attacks on NHS staff occur every day, and this is nothing short of scandalous. Next week we have the Second Reading of a Private Member’s Bill, which has come from the other place, on assaulting emergency workers. Will the Minister confirm whether the Government are minded to support it—and, if not, what further action will be taken to protect health workers?

[Lord O’Shaughnessy]

I agree with the noble Baroness that it is scandalous and that we therefore want to support the Bill. I believe that it will have its Second Reading here on 29 June. I can confirm that the Government will be supporting the Bill.