Learning Disabilities Mortality Review

Baroness Thornton Excerpts

Wednesday 15th May 2019 Lords Chamber

[Baroness Thornton (Lab)]

I thank the Minister for repeating the Statement. I just make the obvious point that the Government have had the draft report since 1 March, and if they had published it in a reasonable time it might not have leaked.

I am sure that we can all agree that people with a learning disability have worse physical and mental health than people without a learning disability, and that the Confidential Inquiry into Premature Deaths of People with Learning Disabilities found that the average age of death from different levels of impairment was between 46 and 67 years, which is massively below the average lifespan for those without a learning disability. I look forward to the report, which the Government have told us that we will soon see.

Will the Minister now say that it is always unacceptable for learning disability to be given as a reason for not resuscitating someone? For this programme to work properly, does she agree that it needs to be resourced so that it can consider all reported cases in a timely manner? I suggest to her that many families feel that the review is the NHS marking its own homework, and that what is required here is a truly independent national body to review the premature deaths of people with learning disabilities.

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her important questions. On her first point, which is that the Government have had the report since March, I should like to be very clear that this is not a government report; it is an independent report from the University of Bristol. It is free to publish it when it is ready, although it was commissioned by NHS England, so the Government are not in control of the timetable for publishing it.

The noble Baroness is 100% right, however, on her point about “do not resuscitate” orders. The reports that we have heard that disabilities such as Down’s syndrome are being used by some doctors as a reason not to resuscitate are entirely unacceptable. We are taking immediate action and a letter will be sent to health professionals to make clear that that is not an acceptable reason to put in place a “do not resuscitate” order. On her last point about resourcing and the effectiveness of the LeDeR programme, progress has been made in implementing it: 15 out of 24 of the recommendations have already been completed, and in others we are making real progress. NHS England has trained more than 2,100 experts to carry out reviews, 1,500 reviews have been completed and a further 1,500 are in progress, but I have no doubt that given the situation in which we find ourselves, questions will be taken into account by NHS England and the department.

Tessa Jowell Brain Cancer Mission

Baroness Thornton Excerpts

Monday 13th May 2019 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I thank the Minister for repeating the Statement. Of course, it is a matter close to the hearts of many noble Lords here, particularly those of us who took part in the debate when Tessa Jowell spoke in this House for the last time. Who could forget Tessa’s determination to fight for change, so that in the future people would not die of brain tumours but that research would lead to prevention, early detection and more effective cures, and that these would be available to everyone throughout the NHS, without being dependent on where you live? I pay tribute to Jess Mills, Tessa’s daughter, and her family for their continuing commitment to fulfilling the challenge that Tessa set all of us, as the noble Baroness quite rightly said.

We know that brain tumours are indiscriminate; they can affect anyone at any age. What is more, they kill more children and adults under the age of 40 than any other cancer, yet historically just 1% of the national spend on cancer research was allocated to this devastating disease. We all welcome the progress made so far by the Government; we congratulate them and support the fact that treatments are now available across the country that were not available when Tessa spoke to us in this House. However, we also know that the NHS faces a cancer diagnostics crisis. Cancer Research UK has pointed to chronic shortages in the diagnostic workforce, with more than one in 10 positions unfilled nationally. Hospitals are reliant on outdated equipment and some of the lowest numbers of MRI and CT scanners in the world. The UK is fourth from bottom in a league table of OECD countries with the lowest number of CT scanners per million inhabitants.

As the Minister rightly said, this is a question of both resourcing and staffing. In today’s Statement, we have been given sight of the key points that have been touched on and we are pleased that it references the upcoming workforce plan. However, it would be useful if she could expand on this point, specifically around the need for a global scientific workforce and the plans for immigration in relation to the research community. Because without the right skills and technical staff in place, a lot of the research funding and momentum achieved in the past year will not amount to very much. She will be aware that a mix of domestic and international scientific talent underpins the UK’s position as a world leader in life sciences. The 2018 immigration White Paper was not fit for purpose, in the view of those on this side of the House. The £30,000 a year salary threshold would have had a devastating impact on the recruitment of junior research capacity and the increased cost and bureaucracy requirements of the visa system. Indeed, the British public recognise the importance of an international research workforce to the UK. Ninety per cent of the public think scientists make a valuable contribution to society and 86% want to increase or maintain the level of immigration of scientists.

While I absolutely accept that progress is being made in the noble Baroness’s department, this question applies across government and I should like some reassurance that that is understood and action is being taken. Neurosurgery is no exception when it comes to the problems of cancer targets. In March 2019, the 18-week completion target for referral to treatment pathways stood at 81.3% for neurosurgery, 5% lower than the average for all specialties. This made neurosurgery the worst-performing specialty, almost certainly because of staffing shortages in these areas. Therefore, while I absolutely welcome the Statement and the progress being made, we all have to accept that we have some way still to go to fulfil the ambition and the targets that Tessa Jowell set us.

[Baroness Jolly (LD)]

My Lords, I thank the Minister for repeating the Statement. I had the honour of responding to Baroness Jowell’s maiden speech on 23 May 2016. I looked it up in Hansard this morning. She recalled Seamus Heaney’s injunction to his wife:

“‘Noli timere’—‘Do not be afraid’”.—[Official Report, 23/5/16; col. 167.]

As it turned out, we did not have long to wait for her to show how fearless she could be. I responded to her maiden speech by saying that I felt sure she would make her mark very soon. Sadly, she did not have as huge an amount of time to make her mark as I had expected—but nobody who was in the Chamber for her valedictory speech in January 2018 will ever forget her demonstration of total fearlessness.

5-ALA received FDA approval for use in the USA on 3 July 2017, just over a year after Baroness Jowell joined your Lordships’ House. Use in the UK was given NICE approval on 10 July 2018, just two months after she died. I clearly welcome today’s announcement, but I have some questions for the Minister about 5-ALA and its rollout. What weight does NICE give to treatments that have received approval by the FDA? Is it usual for a treatment that is so obviously effective to wait nearly a year before being used routinely? Will it be universally available to all those who stand to benefit from it?

NHS: Shortage of GPs and Nurses

Baroness Thornton Excerpts

Wednesday 8th May 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

My noble friend is absolutely right, and he has his own expertise in this area. I am pleased to be able to report that we have had an increase in recruitment of nurses and NHS workers from abroad. Compared with June 2016, we have over 5,200 more EU health and care staff working in the NHS, and we have had a 126% increase in the number of non-EU NHS workers, which shows the attractiveness of working within the NHS. But he is also right that we need to make sure that those who work in the NHS have access to the most innovative and effective tools possible, which is why, particularly within GP practice, we are launching the GP IT Futures programme. That will provide GPs with the best tools possible so that we can make their job more efficient while also allowing them to provide the best-quality care to patients.

[Baroness Thornton (Lab)]

My Lords, I think I need to declare an interest as a member of a CCG; I spend some of my time surrounded by GPs, who are utterly wonderful, and who tell me that morale is not good. The problem is that a lot of GPs are leaving because they are completely fed up with the way that they have been treated by the NHS. That has to be taken account of by the noble Baroness, Lady Harding, as part of her work in bringing forward the plan, and I know it will be.

I am afraid that it does not say much about the current lack of a workforce strategy that we are having to trawl the world to get GPs and nurses to come and work in the UK. I know that other Members of your Lordships’ House have been worried that we are taking nurses, GPs and doctors from countries where they are very much needed. Will the Minister address how to deal with the morale of GPs, as well as the ethics of the UK recruiting nurses and doctors from countries where they are needed?

[Baroness Blackwood of North Oxford]

I slightly question the premise of the noble Baroness’s question, given that I am the daughter of an English doctor and a South African nurse. This has always happened in the NHS, and it is an absolutely acceptable process. Recruitments go back and forth between nations, and that has always been the case.

To move on to the noble Baroness’s question about morale in the NHS, particularly within general practice, it is essential that that is addressed, and she is right that GPs are the bedrock of the NHS now and in the future. That is why we have announced in the long-term plan not only that we are investing an extra £4.5 billion in primary and community care, which is at a faster rate than the rest of investment within the NHS, but the new contract to develop partnerships to provide greater certainty for GPs to plan ahead and to give them the extra 20,000 support workers who can make the job within GP practice more effective and sustainable. That is also why we have announced the GP IT Futures programme to give them the tools that they need to deliver more effective services and to deliver better-quality care, and why we have announced targeted and enhanced recruitment schemes to support and retain GPs within practices, not only in hard-to-reach areas but within the pipeline. That demonstrates that the Government are completely committed to general practice and will retain that commitment as long as we are able to do so.

Antimicrobial Resistance

Baroness Thornton Excerpts

Thursday 2nd May 2019 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, this has been a fascinating debate and revealed again the depth and breadth of the knowledge and passion your Lordships’ House has on this issue. I thank the noble Lord, Lord Lansley, for initiating the debate and the Library and many other organisations for their helpful briefings. I feel I should declare that I am a member of a CCG. I say that because it is rare to see a subject that is the victim of as many acronyms as the NHS, but this field certainly challenges that, combining as it does health, farming and the environment, the research and science communities, pharma businesses and international organisations. I was very grateful for the list of acronyms at the front of the Government’s five-year paper.

As noble Lords have said, we know that AMR currently results in 700,000 deaths globally every year, that by 2050 that could be 10 million, and that it threatens to turn back the clock on a century of medicine, rendering modern surgery, organ transplantation and chemotherapy too dangerous to use. Preventive treatment is needed, as the report says, to curb the spread of bacterial diseases requiring antibiotics. As the noble Baroness, Lady Walmsley, said, vaccines are the most effective preventive health tool in human history. We therefore need to expand the use of existing vaccines to have a better impact.

One of the most serious issues in the fight against AMR, which almost every noble Lord mentioned, is that no new class of antibiotics has been introduced for more than 30 years. Antibiotics are quite unlike any other category of drug, because every dose of antibiotics poses the risk of encouraging bacteria to adapt and develop resistance. That was illustrated by the noble Baroness, Lady Masham, in her description of the fight she has been having, which we have discussed on several occasions over the past year.

The Government’s five-year action plan is indeed an impressive document and a step along the road. I join the noble Lord, Lord Lansley, in saying that we may not be moving as quickly as we should. That has been echoed across the Chamber. Of course, it is not the complete solution, and serious questions have been asked in the debate. I join the noble Baroness, Lady Miller of Chilthorne Domer, in saying that the plan is disappointing in that it fails to give a clear commitment to incorporate into domestic law the European Union’s recently agreed legislation that bans routine preventive use of antimicrobials. It is a pertinent question at this point. Article 107.1 provides:

“Antimicrobial medicinal products shall not be applied routinely nor used to compensate for poor hygiene, inadequate animal husbandry or lack of care or to compensate for poor farm management”.


That is not being incorporated into UK law, as far as we can tell. I agree with the noble Baroness that the answers given to questions in the Commons were ambiguous, to put it mildly. Perhaps the Minister could take this opportunity to clarify the issue.

When I discussed the five-year plan with my noble friend Lord Winston, who regrets that he cannot join us this afternoon, he said two things to me. The first was that meeting this challenge will be well-nigh impossible given the dearth of lab, technical and science staff in the NHS at this moment. Secondly, he said that investment in research needs to be much greater and the follow-through more effective. My noble friend would have put those points more eloquently and, probably, more forcefully than I have, but neither of those issues is new; they have been articulated in your Lordships’ House over a long period.

Part of the NHS long-term plan talks about the delivery of the five-year plan we are discussing today. Will the staffing review address technical staff, of which there is a terrible shortage? They are essential for the delivery of both the NHS long-term plan and this plan. We know that the issue of research is not just about funding to deliver ground-breaking research. The UK does a great job in training PhD students, but loses a lot of talented people because the post-doctoral period is so unstable. We need continued support for interdisciplinary networks to strengthen research and develop capacity. Does the strategy address that issue as robustly as the emergency that we are facing requires?

Many noble Lords mentioned market failure, which the noble Lord, Lord Lansley, dwelled on in his opening remarks. According to Professor Dame Sally Davies, the reason for that is in part that the easy wins have been made and there is now a fundamental failure of the market for new antibiotics. Given the growing threat of AMR and the need to conserve and use current and future antibiotics carefully to preserve their effectiveness for as long as possible, it is clear that pharmaceutical companies are aware that any new antibiotic they bring to market will be prescribed only very sparingly rather than as a first-line treatment during its patent life, thereby reducing its profitability. I found that idea very dispiriting because it seems that we must address market failure. The report of the noble Lord, Lord O’Neill of Gatley, also recognised and addressed this issue.

That is even more discouraging when one realises that, over the past five years, we have seen pharmaceutical companies withdraw further and further from the development of antibiotics. In June last year, the latest company, Novartis, exited the market, bringing the total number of companies involved in antimicrobial drug development to six. The issues of market failure and disinvestment are incredibly important; therefore, the Government’s scheme to delink the price paid for antimicrobials from the volume sold is also crucial.

Even more depressingly, Professor Dame Sally Davies argued that the industry needed to step up and act in a socially responsible way, pointing out that tackling AMR was also in its interest. In her evidence to the Commons Select Committee, whose report I found extremely useful, she said:

“I am disappointed by the number of them”—


pharmaceutical companies—

“who have said quietly over a drink, ‘Well, Sally, we know you’re going to solve this. The Government will have to pay, so we’re waiting until you pay’”.

Where is the social responsibility? What terrible short-sightedness. To go back to the point about losing modern medicine, what is the point of developing the world’s greatest cancer portfolio if there are no antibiotics to rescue the patients? Yet industry expects us in government and the public sector to fund this, or that it will happen through somebody else being corporately responsible.

This market failure might lead to catastrophic consequences, as referred to on pages 74 and 76 of the five-year plan. It rightly states:

“The UK cannot solve such market failures alone”.


I question that because I should not like to think that the idea that we cannot solve this alone because we are 3% of the world market means that we do not try to do things in this country to turn this round. Our NHS has huge purchasing power: it pays billions of pounds to pharma, which makes billions in profit from these sales, for the drugs and treatments we need. We must have some leverage here. I ask the Minister: if a UK university or small pharma company found a new antibiotic, surely our Government would find a way to make sure that it was developed and brought to market. They would not wait for this to happen on the world stage, would they? I really want to hear that we will not have a repeat in the UK of the situation described in the MRC report, as referred to by the noble Lord, Lord Lansley. I received that report; the story of Achaogen was a graphic one of market failure in developing a new antibiotic. However, the noble Lord did not ask something that I wish to ask: what will happen to that drug? Achaogen developed a drug that can treat the most serious superbugs; therefore, it is not much needed so the company did not make enough money and went bankrupt. Where has that drug gone? What has happened to it? That is an important question.

[Lord Lansley]

As I understand it, the company is up for sale so, effectively, people would buy the patent and the drug.

[Baroness Thornton]

Let us hope that the people who buy it are public-spirited enough to know that they need to develop it and that that can be done. That puzzled me when I read the fascinating article, which I recommend to noble Lords. I thought, “A new antibiotic is out there and it is not available to us, for goodness’ sake”.

I congratulate the Government on the five-year plan. It is important, however, that the impetus behind it works, that the incentivisation schemes unlock investment in AMR, that we do not face the same issues being faced in America, and that implementation of the plan is speeded up.

NHS Funding: Mental Health Services

Baroness Thornton Excerpts

Wednesday 1st May 2019 Lords Chamber

[Lord Bradley]

To ask Her Majesty’s Government what proportion of the additional money allocated to the National Health Service budget over each of the next five years will be ring-fenced for the development of mental health services.

[Baroness Thornton (Lab)]

With his consent, I beg leave to ask the Question standing on the Order Paper in the name of my noble friend Lord Bradley. Noble Lords will know why he cannot be with us today, and the House will wish to know how much he and his family appreciate the sympathy that has been expressed.

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

My Lords, NHS England and NHS Improvement have set out their commitment to increase mental health spending by at least £2.3 billion in real terms between 2018-19 and 2023-24. In five years, this will represent over 10% of NHS England’s additional settlement. More details of how the long-term plan will be resourced will appear in the implementation framework, which is due to be published soon.

[Baroness Thornton]

I thank the noble Baroness for that Answer. Given that mental health illnesses account for 28% of the burden of illness in the NHS but receive only 13% of its funding, I find her Answer very confusing. Can she be more precise? This is not just about the number of staff required but about how much will be required to achieve parity of esteem and over what period.

[Baroness Blackwood of North Oxford]

I thank the noble Baroness, Lady Thornton, for her question on behalf of the noble Lord, Lord Bradley. I am sure that the whole House will want to join me in sending him and his family our support at this difficult time.

The noble Baroness has asked a very important question. The mental health budget will increase by £2.3 billion by 2023-24, growing faster than the wider budget. We are using transparency to drive improvements. The mental health dashboard shows that last year, for the first time, all CCGs met the mental health investment standard, which is an encouraging sign. This builds on the work done in the five-year forward view, which delivered real improvements for patients. It delivered £247 million for liaison psychiatry, £290 million for perinatal services and £400 million for crisis resolution and home treatment teams. However, we will not rest there. The long-term plan will deliver much more for patients, including 345,000 more children and young patients to receive specialist support services. This is the ambition that we have and the ambition that we will deliver.

National Institute for Health and Care Excellence (Miscellaneous Amendments) Regulations 2018

Baroness Thornton Excerpts

Wednesday 1st May 2019 Lords Chamber

[Baroness Thornton (Lab)]

I thank my noble friend for bringing this matter to the Floor of the House and for leading this short discussion. I too have many questions for the Minister but many of the questions that I would have asked have already been asked by my noble friend and the noble Baroness, Lady Jolly. It seems that our concerns are very similar. I agree with the noble Baroness, Lady Jolly, that when I read through the notes accompanying this regulation, it seemed puzzling that the consultation had produced a majority against this process, and I too was not completely convinced by the Government’s justification. That must lead to something which we can probably call cuts and wanting to save money. To want to save money with an organisation which is so integral to our NHS infrastructure and so important to ensuring the efficacy and cost benefit of and access to medicines and procedures is not a sensible way to proceed.

Some of my other questions centre around a concern about the impact that these charges will have on the jewel in the crown that is the UK-based science industry, particularly at a time when there is already such uncertainty with the dual impact of Brexit and these charges. It seems that the additional costs for a market may diminish the UK’s attractiveness for life science businesses, which has already been mentioned, and may also mean that NHS patients get access to new therapies later than those in other countries across Europe, which my noble friend also alluded to. Has there been an assessment of the impact of these charges on the UK bioindustry and its attractiveness to the international life science community, and of the UK as a location to research, develop and launch innovative medicines?

What will be the impact on patients? The UK BioIndustry Association has stated its concerns that the charges for technology appraisals could either prohibit or delay patient access to medicines in England. This could result in inequalities across the UK, as medicines may be available in Wales and Scotland, where charges for technology appraisals have not been introduced, before receiving approval for use on the NHS in England. That might disproportionately affect patients with very rare conditions, and therefore might also undermine the UK rare disease strategy to ensure equity of access across all four nations of the UK. Have the Government considered not only the financial impact but the potential impact on patient health? Do the Government have a strategy in place to mitigate delays in patient access to medicines that may come from these charges?

I join the noble Baroness, Lady Jolly, in asking whether there will be a review of the impact of this proposal, when that will take place, and when we will learn about the impact of this proposal on NICE and the NHS infrastructure. That will be important. We need to review this, because I fear that it may be a wrong decision.

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

I thank all noble Lords who have contributed and congratulate the noble Lord, Lord Hunt, on securing this debate. It is an important subject and it is right that we take time to consider it. I know that he takes a keen interest in NICE’s work from his previous role as the first Minister with responsibility for NICE, and it is a privilege to have taken on his mantle some years later.

This year marks a significant milestone for NICE, as it celebrates its 20th anniversary, during which time it has transformed the way in which decisions are made in the health and care system. I echo the comments made by the noble Baroness, Lady Thornton, who referred to NICE as a jewel in the crown of the UK life sciences ecosystem. She is absolutely right that we must ensure that we not only protect it but promote its success. Since its inception, NICE has played a vital role, not only in securing maximum value from health spending but in ensuring that patients are able to benefit from rapid access to effective new drugs and other treatments. The noble Lord, Lord Hunt, hit the nail on the head when he said that that balancing act in the health system is so challenging.

Of course, the NHS is required to fund the treatments recommended through NICE’s technology appraisals and HST evaluation programmes, so that they can be provided if a patient’s doctor says that they are clinically appropriate for the patient. Over the past 20 years, more than 80% of NICE’s recommendations have supported use of the technology assessed, meaning that many thousands of patients have benefited from rapid access to effective new treatments. A less-frequently reported statistic is that 75% of HST applications have also gone through, which is encouraging.

Recent IQVIA research has just been published which showed that, despite some of the frustrations we have with update and access—which is something we are working hard on—the UK is in fact one of the fastest countries in Europe to get products through its regulatory system. We can be very proud of that, and must protect it.

I know that your Lordships will agree not only that it is extremely important that we have a system such as NICE in place to ensure the NHS spends its money in the most effective way possible, but also that it is critical that NICE operates on a sustainable footing so that it continues to be responsive to developments in the life sciences sector, to which noble Lords all referred.

To date, as has been mentioned, NICE’s TA and HST programmes have been funded through government resources but, as is common with government bodies, it is right that NICE considers how to operate to the utmost efficiency, and that those who stand to benefit from services contribute.

This is standard procedure and a standard model for many organisations and ALBs such as NICE. It is standard for the MHRA, the HTA, the CQC and for HTAs in other countries, so we are not operating an unusual procedure here, as the noble Lord, Lord Hunt, mentioned. I was grateful for his support for the charging model.

However, recognising the need for sustainability must be balanced with the imperative to encourage innovation, and the Government and NICE believe that the most appropriate and sustainable model for NICE’s TA programmes in future is for it to levy a proportionate charge on companies that benefit directly from its recommendations. This goes right back to a recommendation of the triennial review of NICE in 2015, so long-term work has been going on in this area. Recognising the importance of getting it right, the Government consulted on the draft regulations. That consultation has been referred to by noble Lords. At that point, as part of those proposals, the Government proposed the 25% discount for small companies. The consultation also sought views on a proposal to enable NICE to recruit appeal panel members engaged in the provision of healthcare in the health services across the UK instead of just England. This has not been mentioned and I know is widely supported, but I just wanted to point out that fact, which we are very pleased about.

As was raised by the noble Baronesses, Lady Thornton and Lady Jolly, there were 78 responses to the consultation, around half of which represented views from the life sciences industry, including pharma companies, industry representatives, consultancies and medtech companies. Other responses came from patient groups, NHS organisations and individuals. Although, as has been said, the majority of respondents—62%—disagreed with the specifics of the proposal to charge companies for making recommendations, the analysis showed that just over half of respondents agreed that life sciences companies should contribute to the cost of developing NICE recommendations, which is why further work was done to develop the charging proposal but refine it.

Respondents also supported, by 59%, a mechanism for reducing the impact on small companies, but felt that the proposed 25% discount did not go far enough. Other more specific concerns were raised about the potential impact on patient access to new treatments, in particular for rare diseases, the impact on NICE’s independence, and the analysis contained in the impact assessment.

The SLSC also picked up on issues in its report, and I will address some of those in response to points raised by the noble Baronesses, Lady Thornton and Lady Jolly. The Government considered the issues raised in the consultation very carefully and carried out further analysis to feed into the final impact assessment. We concluded that it was appropriate to make two main changes to the policy in light of the consultation responses. These particularly dealt with concerns about the design of the charging with respect to SMEs. I know that noble Lords are well aware of those concerns.

There is an increased discount for small companies of 75%, to minimise barriers to the participation of small companies wishing to bring forward new products. I realise that many feel that that did not go far enough but, to address that concern, it also included the new power to enable the Secretary of State to direct NICE in specific cases to calculate charges on what it considers to be the appropriate commercial basis. This provides more flexibility for amending charges, should that be required in future, subject to consultation with stakeholders. For example, we may see different types of innovation, including devices or digital products going through TA programmes, and this provides flexibility for the Secretary of State to direct NICE to propose charges at a level appropriate to those markets. I think that responds to the point raised by the noble Lord, Lord Hunt.

Social Media and Health

Baroness Thornton Excerpts

Tuesday 30th April 2019 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I thank the Minister for repeating this important Statement. This discussion provides a good backdrop to the debate to follow, on the online harms White Paper. There are essentially two matters of concern here: online harm and false news, which includes the health impact of anti-vax material.

After the scandal that followed the death of Molly Russell, and the bravery of her father in speaking out against the online harm perpetrated by platforms such as Instagram, we were promised decisive action, and the tragedy gave serious momentum to the content of the online harms White Paper. Mr Russell tweeted a link to a Telegraph article yesterday, saying that he had challenged Instagram and the company has said that it will now act. Coming out of yesterday’s hour-long meeting with the industry, the Secretary of State announced a few hundred thousand pounds in donations to the Samaritans for research into online harm, which is of course welcome. However, these social media platforms must be made to take responsibility for the harmful content and dangerous fake news they host.

Instagram said that it would ban all graphic and non-graphic images of self-harm in February. As far as I can see, it has not done so. Like my honourable friend Jon Ashworth MP in the Commons earlier, I did a test a couple of hours ago. To be more accurate, since I am not an Instagram subscriber, I got my researcher to demonstrate for me what happens if you type into Instagram’s search engine the term “self-harm”. You get several columns of results; the first is called “Top Results” and does not produce any links. It says that no content can be found, which is good, but I am afraid the content is still there. If you click on the next column, headed “Accounts”, there are hundreds of accounts concerning self-harm that you can access. If you click on the third column, headed “Tags”, there are 725,000 posts that mention self-harm. Some may direct you to get help but most will not, and some show graphic self-harm pictures and videos. Some of them romanticise, if you can imagine such a thing, this activity. As any health expert will tell you, for those youngsters—some are very young indeed—these are the triggers to self-harm.

The noble Baroness says that Instagram now has a policy of globally removing graphic self-harm imagery. As far as I can see, it has not done so yet. The same applies to websites concerning suicide. If you search for “#killmyself”, you will find huge numbers of results; ditto if you search for “eating disorders”. Research shows that 22 % of young adults report self-harm and suicide-related internet use. This is a crisis. There may be many reasons for this figure, and many solutions, but the internet must take responsibility for the content it contributes to this. Did the Secretary of State challenge Instagram on the assertion that it had taken down content? Has he done what my honourable friend and I did and tested it himself?

Did Instagram give a timescale, or is it waiting for the Samaritans’ research? That seems to me to be not an acceptable solution right now. I welcome the involvement of the Samaritans, but not if it means a further delay to action. It does not need research to know that the content of some of these sites is totally unacceptable and needs to be got rid of. Perhaps the noble Baroness can explain what the Samaritans’ research will be used for and its timescale? These are very, very rich organisations, and a few hundred thousand pounds to the Samaritans does not mean they can offload their responsibility to deal with this content; they have billions of pounds that can be used for this purpose.

The reason I am concerned is that these companies have form. Over many years of warm words and no change, they have consistently resisted taking responsibility for the content they carry. They have had to be pulled, kicking and screaming at every turn, into behaving with responsibility. I repeat: will the Secretary of State test this by looking at it himself?

The content of these platforms is why the White Paper is so urgently needed. I want to ask only one question about it; the debate will take place in a few moments and my noble friend will certainly pose many questions. However, if a young person even accidently accesses, for example, a self-harm image, there is a likelihood that the algorithms—which look at what every one of us is accessing online—will pick this up. While noble Lords may receive unwanted information about house extensions or the cost of flights, such a youngster may find that they are being led to more sites depicting self-harm. In other words, the algorithms can reinforce harmful content. How will the Government seek to mitigate this unintended consequence?

I turn now to the use of false information in anti-vax campaigns, which has led to a massive increase in outbreaks of measles, as the noble Baroness said in her Statement. The issue here is not just the dangerous anti-vax propaganda on platforms such as Facebook, or indeed Amazon. A story in today’s Guardian says that a young person was delivered a book, and inserted in it was an anti-vax leaflet. One has to ask how on earth it got there. The wider issue is that of public health policy and resourcing.

Are the Government considering banning unvaccinated children from schools in England, as the Secretary of State suggested on the radio last week? I hope not. Do the Government have a clear vaccination action plan? Public health services have been cut by £800 million and, in recent years, health visitors have been cut by 8% and school nurses by 24%. This will not help with the vaccination drive. Will the Government commit to reversing public health cuts and cuts to health visitors, and invest in general practice to meet the recommended 95% national vaccination coverage rate, as recommended by the World Health Organization?

[Baroness Jolly (LD)]

My Lords, I too thank the Minister for repeating the Statement. I am sure nobody in your Lordships’ House doubts the benefits, as well as the dangers, of social media. As the noble Baroness, Lady Thornton, has just stated, the tech giants really need to recognise their responsibilities by taking action now to remove material that could damage the vulnerable.

I would like to link the Statement with the NHS Long Term Plan. In it, there is a commitment to increase spending on children’s and adult mental health services. What figure will this amount to? How much of it does the department anticipate will be earmarked for technology? Where will it be directed? Who will receive the money? What does the department expect the NHS to do to support this move? What criteria will govern its use?

Vaccination uptake is clearly a current issue. How does the department anticipate that social media can help and not hinder the uptake of these life-saving shots?

NHS Mandate

Baroness Thornton Excerpts

Thursday 25th April 2019 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I thank the Minister for repeating the Answer to the Urgent Question asked by my honourable friend Jonathan Ashworth in the Commons earlier today. Why was it necessary to ask that question at all? I hope the Minister may be slightly embarrassed by the lack of courtesy in not informing Parliament of the delay in laying the mandate for NHS England before Parliament in a timely fashion. That is the first time that has happened since the Health and Social Care Act 2012 came into operation. She must also recognise that this is a very important matter. The Secretary of State appears to have ignored the statutory obligation which was much debated and discussed in your Lordships’ House before that Act was passed. Your Lordships placed huge importance on the mandate and the fact that this was how the NHS would be held to account.

Why was this deadline missed? The answer—that the NHS was busy doing the plan and such things—is not adequate. This is about accountability to Parliament. We need to discuss why targets in last year’s mandate have not been met. This is a serious omission for the mandate because it sets the objectives that the Government expect NHS England to achieve, as well as its budget. I absolutely accept that the Government are committed to the budget and the plan, but they do need to address, with some apology, the lack of accountability that this omission means.

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her question. I refer to the comments by Simon Stevens in the PAC yesterday, when he laid out how he sees the situation for the NHS:

“We have an agreed direction in the long-term plan … We have the budget set for the next year, and we have the NHS annual planning process … wrapped up. 2019-20 is … a transition year into stepping into the new five-year long-term plan”.


As the noble Baroness knows, planning guidance for 2019-20 was updated in January when the long-term plan was published. For all practical purposes, this document sets the decision-making for local NHS decision-makers during this year. The national implementation programme for the long-term plan, which will set the longer-term milestones for delivery of the plan until 2023-24, will be published at the end of this year. The mandate and its accountability framework is an important accountability mechanism and strategy document for the NHS. It is taking longer partly because of the close working of NHSE and NHSI and the transitional nature of this year.

It is important that this document does come out, for the purposes of strategy and accountability, but it is most important that it is got right. That is why it is taking slightly longer. I look forward to the debate this House will have when it is published. I am sure that the noble Baroness will hold us to account in the usual manner.

Mental Capacity (Amendment) Bill [HL]

Baroness Thornton Excerpts

Ping Pong (Hansard): House of Lords
Wednesday 24th April 2019 Lords Chamber

My other big concern was about independent hospitals. I have spent a lot of time in my career visiting these places and finding the most vulnerable people with learning or physical disabilities, mental health problems and the rest of it very often tucked away hundreds of miles from their home. Originally the idea was that the independent hospital would be responsible for the assessment and the whole business of deprivation of liberty. In my view, that idea was absolutely horrendous, and, as I understand it, the Government have accepted that and will make sure that the local authority, ideally in the place the person comes from, will be responsible for that process, and therefore the pressure will be to get those people out of those hospitals and back into their community. This again seems to be a minor adjustment made as a result of the work of this House, but for the individuals concerned it is a very significant benefit. So I congratulate both Ministers who have been involved in this Bill, and the Bill team, on the work they have done to respond to concerns expressed by Members across this House. They have done the best they could, so I thank the Minister.

[Baroness Thornton (Lab)]

My Lords, it is always a good moment when we get to this point in any legislation. It is also an opportunity for us to look at where we started in July. In July, my Chief Whip spoke to me about a really small, uncontroversial Bill that would amend the Mental Capacity Act. I am not criticising him, because that is what he had been told. The idea was that we would have the Second Reading quickly before the Summer Recess and then move straight into Committee immediately after it and get through the Bill quite quickly. It is a great testament to this House that we recognised quite quickly that it might be a small Bill but it was certainly not uncontroversial. As I said when we moved into Committee, the noble Baronesses, Lady Jolly and Lady Barker, and I were sending each other messages about this Bill when we were all poolside in different parts of Europe because we realised that we needed to understand it much better.

I do not accept the criticism that we have failed. I think we started off with a flawed Bill and that we have improved it. In a few years’ time I think we will almost certainly return to this subject, because by then we will have discovered things that have not worked out and that need to be reviewed and possibly changed. We need to thank both Ministers for listening, hearing and working to change the Bill. I particularly thank my fellow Peers for working so co-operatively and with such great expertise. It is always a pleasure when we do that and we are always at our most effective when we do so, and I have been very happy that various Members of the House have taken the lead on various issues throughout the passage of the Bill. The Minister named everybody, so I shall not do so again, but they know who they are and it has been a pleasure to work with them.

We should be pleased that we have successfully tackled what, as far as we were concerned, were certain huge issues, many of which have been mentioned by the noble Baroness, Lady Barker. They included care home managers’ powers, conflicts of interest, private hospitals, the definition of deprivation of liberty and the information provided. We should be proud that those issues have been tackled. I particularly thank the noble Lord, Lord O’Shaughnessy. I have not often been called a juggernaut but on Report he suggested that I was. I think he was expressing the opinion that in my remarks I was representing the views of the whole House and that we were definitely coming for him, as it were.

If we are to learn some lessons from this, one is possibly that the Bill team took a little while to gear up to what happens in the House of Lords and how we approach things. We talk to the stakeholders—we have a continuous dialogue with them—and that is the next group that I would like to thank. I thank all the stakeholders who came to endless meetings with us to make sure that we did our job properly, although some of them still have some major concerns.

I say to the House that what matters is what happens next. First, it seems likely that within the next year or so we will have another mental health Bill, so it is quite possible that some of the issues that we have been concerned about will re-emerge and be discussed during that process. Secondly, we will have the regulations and the code of practice. I would like to be assured that the consultation, which might not have been quite as good as it should have been at the beginning of this whole process, will absolutely inform the code of practice and the regulations that follow the implementation of this legislation.

I do not wish to threaten the Minister but, after the past eight or nine months, there is a body of commitment and passion over this issue that will certainly be watching and be interested in what happens next and will have something to say about it. Therefore, in a spirit of positiveness, we hope that we will be able to help with the next stages but we will certainly be watching them to make sure that the gains that we have made are reflected in the code of practice and the regulations.

Finally, I very much thank the Minister, who came in in the middle of the Bill. This is the second Bill that she has had to pick up and run with in your Lordships’ House. She has done it with great dignity and intelligence, and it has been a pleasure to work with her.

[Baroness Blackwood of North Oxford]

I thank noble Lords for an important moment in the passage of the Bill. I assure them that they will never have to threaten me to get me to listen to important points regarding the progression of legislation of this import. I identify myself with the comments of the noble Baroness, Lady Tyler. This is indeed a pragmatic solution to the very challenging problem of getting the right solution.

I also echo the comments of the noble Baroness, Lady Finlay, who said that this has been a bumpy ride, but it is a major decision to deprive someone of their liberty, so it is right that there has been very detailed scrutiny of the legislation. When someone is deprived of their liberty we have to ensure that it is always necessary and proportionate and, wherever possible, consistent with their wishes and feelings. I agree with her that the advocacy provisions in this Bill are stronger than in the DoLS legislation, and that it will provide greater responsiveness and flexibility than previous legislation. We can be proud as a House to have delivered that.

I am sorry to hear the concerns raised by the noble Baroness, Lady Murphy. As we proceed through the next stages of engagement over the code of practice, I hope that we shall be able to prove her wrong, in the most positive sense. We have put in place very strong measures for whistleblowing thanks to the contribution of the noble Baroness, Lady Watkins; thanks also to her work, we have strengthened the provisions for information. We have also to nail down the questions around the definition, of course, but I think it right that this is not on the face of the Bill for all the reasons that we have debated at great length in this Chamber. I will not rehearse them now but will try to answer some of the questions that I was asked.

The first is about when the code of practice will be published. Obviously, as the noble Baroness, Lady Finlay, pointed out, the department is collaborating very closely with the sector in the preparation of the code; that is already happening. We are working with many organisations and individuals. The drafting will be considered by expert reference groups and people with lived experiences, to ensure that we get the most practical and workable code of practice. The department has already convened a working group involving a wide range of stakeholders. We expect to have output from the working group by this summer. After Royal Assent, I will place a letter in the Commons Library as requested; this will contain timescales for the code of practice, including when a draft code will be published for consultation. I hope that is reassuring.

As I have said, the statutory guidance will include a suite of case studies which will demonstrate how the definition applies in different settings and scenarios. It will provide clarity and aid to practitioners. We are collaborating to ensure that it can provide clarity and lack of ambiguity and can be a real help to those using it. As the noble Baroness, Lady Tyler, said, we have made a commitment that it will provide detail about when deprivation of liberty does and does not occur. It will reflect existing case law, including the Ferreira decision, and it will set out the meaning of a deprivation of liberty in a positive framing; this should be reassuring. On the question of a review, the code can be updated at any point. This will ensure that it can reflect changes in legislation practice or case law—that is, the entire code, not just the definition. I hope that is reassuring.

I would like to respond also to some of the points made by the noble Baroness, Lady Barker. She is absolutely right regarding the questions of resourcing, the backlog and training. We are very alive to this. A further impact assessment will be done following Royal Assent and we will work with stakeholders collaboratively to take on board feedback from previous iterations. We will also ensure that the Government will provide guidance ahead of implementation. That will include steps that can be taken to help reduce the backlog.

However, we will not stop there. The Government are committed to supporting training ahead of the new system coming into force and are working with Skills for Care, Health Education England and Social Work England to deliver that. Ahead of day one, we will work with local and national networks and the Welsh DoLS network, in partnership with the LGA and ADASS, to reduce the existing backlog. Work is under way for that. Cared-for persons who have existing DoLS authorisation on day one will remain under that authorisation until it expires, after which a new application will be needed to try to manage the volume of work that will be undertaken. I hope this is reassuring. To respond to the point raised by the noble Baroness, Lady Finlay, I can assure her categorically that the code of practice will be statutory.

I hope that all this is reassuring; I think this is a great step forward and I commend the Bill to the House.

Tobacco Harm Reduction

Baroness Thornton Excerpts

Tuesday 2nd April 2019 Lords Chamber

[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.