Health Service Safety Investigations Bill [HL]

Baroness Walmsley Excerpts

2nd reading (Hansard): House of Lords
Tuesday 29th October 2019 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I too thank the Minister for introducing this Bill.

I have always believed that, if you want to know what is wrong in an organisation, the best thing you can do is ask the people who work there. They will also very often know what to do about it. If you want to manage change effectively, your first principle has to be to involve in its design those who are going to implement it. I am also, as a keen gardener, a fan of the old saying that the best fertiliser is the farmer’s boot. In other words, there is no substitute for getting round the farm to see what is growing well and what is being eaten by caterpillars. The same goes for organisations. If managers do not get out of their offices to see how things are working on the ground, they will miss what is going wrong and lose out on valuable opportunities to hear from staff informally. Nowhere is that more important than in an organisation where people’s lives depend on getting things right the first time.

We therefore welcome the Government’s objective of moving towards a learning culture, but in many good NHS organisations this is nothing new. There have been many successes when the principles I have just outlined have been put into operation and staff have embraced change, especially when it was their idea in the first place—or at least they believed it was. Sometimes small management and systems changes can make a big difference to patient safety: for example, the introduction of checklists in surgery has reduced mistakes considerably. These things are not the responsibility of any one member of staff but involve people working together. The Bill deals with thematic or systemic issues rather than individual cases so it has a rather different role from the existing systems for improvement and safety management, but I would like to know how its operation will link with and impact on those existing systems.

Getting to the bottom of problems in the past has often been hindered by staff hesitating to report concerns because of worry about being victimised as a whistleblower —there have been some very bad cases of that—but also because of a lack of confidence that anything will be done. The safe space idea should help with this. However, I agree with the noble Lord, Lord Hunt of Kings Heath, that it has to be seen that the recommendations are put into place for that confidence to arrive.

Currently, the duty of candour means that staff must express concerns when they believe there is an unsafe situation. However, the RCN tells us that half of those who do so are not convinced that any action has been taken. As the noble Lord, Lord Hunt, said, it will be a challenge to the new body to ensure that those who give evidence in the new safe space see that effective safety improvements are put in place as a result of their co-operation. It is also important that those who give evidence are not inadvertently put at risk by doing so. That means that the exemptions to disclosing information to other bodies must be narrow, clearly defined and well understood. I think my noble friend Lady Parminter will say something about the Parliamentary and Health Service Ombudsman, which feels that it should be treated the same as coroners. There must also be clearly understood definitions of what serious professional misconduct means.

Therefore, to fulfil the ambitions for the HSSIB, investigations must look at the whole picture, not just at the individuals involved in any incident. They must consider whether the shift at the time of the incident contained an appropriate number of staff for safe working, with the correct skill mix, training and experience for the situation they find themselves in. For example, we know that there are currently 40,000 nursing vacancies, and half of nurses in a recent RCN poll reported that their last shift was understaffed. Brexit has and will make things worse.

The investigations should also consider local and national policy and report on how they impacted the incident, and should be able to make recommendations to the Secretary of State about the need for structural changes indicated by the investigation. That is why it is so important that the organisation is independent. How do the Government plan to ensure that the recruitment of the board is really independent of government and includes lay members as well as medical professionals? Again, I agree with the noble Lord, Lord Hunt of Kings Heath, about the appointment of the chief investigator and the involvement of the Secretary of State.

It is arguable that all patients, however funded, should be able to benefit from the work of the HSSIB. Are there plans to extend its remit, after a period, to all health services, including those provided by independent providers? Indeed, the BMA has already suggested that its remit should be extended to incidents that affect the safety of healthcare workers as well as patients. In Committee there will be discussions about the potential expansion of the remit. Can the Minister clarify the relationship with other bodies with responsibility for quality and safety in health and care such as the CQC and the various regulators? Also, there are already various pathways that staff can take to express concerns, so there needs to be clear guidance as to which path to take in each situation.

Resources for up to 30 investigations per year are being provided. How has this number been arrived at? What if a serious qualifying incident happens just after the annual budget has run out? Will the HSSIB have to publish the number of incidents referred to it alongside the number conducted, to determine whether further resources are needed in the future?

How will decisions on the criteria for investigations be made? The groups consulted should be as wide as possible, including patient groups as well as healthcare professionals and managers. The Secretary of State seems to have a slightly suspiciously large role in an organisation that is supposed to be independent.

As I said, I welcome the safe space approach, but it is important that staff feel supported when they disclose what happened, especially if their view with hindsight is slightly different from what they might have said at the time. The primary objective of learning from mistakes will be achieved only through full disclosure to the investigators, and that will come only from confidence in the system.

We welcome the plan to put the new medical examiners on a statutory footing. It is important that bereaved families are helped to understand what happened and, if there is any doubt about the cause of death, that further investigations are put in place. Of course, we need the right sort of people for this with the right sort of training. It is essential that the service is properly resourced, particularly if it requires input from staff who are already stretched in their ability to provide good-quality and timely care to patients. Will the Minister say something about the staffing model for medical examiners? If they are to examine all deaths apart from those that go to coroners, there will be times of the year when they are very busy indeed, such as the winter months or in a heatwave. This is the same time when all clinicians are very busy, so if the MEs are clinicians employed elsewhere, doing shifts as medical examiners as well as their other job, they may need to be in two places at once at some times of year. How will the staffing model be designed to be resilient in that situation?

In summary, one could hardly be against a plan to develop more of a learning culture in the NHS and enhance patient safety, but there are questions to be answered and reassurances to be given, and I hope that the Minister will be able to do that.

Queen’s Speech

Baroness Walmsley Excerpts

Tuesday 22nd October 2019 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I have recently had cause to be very grateful to the NHS and its dedicated staff. However, a service that leaves a vulnerable elderly patient in A&E waiting seven hours to see a doctor and, on two other occasions, waiting in A&E for a bed in a ward for 12 hours and overnight is a service that is either inadequately resourced or inadequately staffed, and probably both. Patients are well named in the health service of today.

The health service relies on a thriving economy to provide its funding. This Government have played fast and loose with the prospects for our health service by their relentless pursuit of the hardest of hard exits from the European Union, within which our economy has thrived for more than 40 years. Brexit has already cost our economy £70 billion. It has also hit NHS staffing hard, with many well-trained and well-motivated staff either going home or not coming here at all.

Why are so many A&E departments not reaching the target of seeing 95% of patients within four hours? It is not because the staff are not working hard. Clearly the reasons are complex, and demographics play a part. There are people who go to A&E who could have used other services. Here, I stress that all three visits I mentioned earlier were made after all other sources of help had been tried.

However, two elements of the problem are outside A&E. One is delayed transfers of care, meaning that beds are occupied by patients who would be much better off at home with support or in social care. The second lies in primary care. Therefore, when I heard the Prime Minister’s headline-grabbing claim that his Government will build 40 new hospitals, I looked at it very closely and found that it is really only six new hospitals and a bit of seed corn money for the rest. More importantly, I realise that this unelected Prime Minister has no idea what the problem really is if he thinks that the solution is six new hospitals.

Patients who cannot get to see their GP will go where the lights are on, and that is A&E. It is very common for patients to have to wait three weeks to see their GP, and that is unacceptable. In many parts of the country, there are not enough GPs. In some places, this problem has been tackled by GP practices taking on other professionals to lighten the load on the doctor. This is an enlightened approach but it requires forward planning, funding and suitable premises. In the case of my local primary care services, that is not happening. There are no suitable premises for a modern all-service primary care facility, and that can make it hard to attract GPs. Therefore, to move to an efficient primary care service and reduce the pressure on A&E, we need funding and planning, but we are unlikely to get that from a Government intent on damaging our economy and promising not to increase taxes. Of course, the best course is to avoid damaging our economy and our health service by remaining in the EU.

The other way to reduce pressure on our health services is to prevent ill health, and I absolutely agree with the gist of the speech of the noble Lord, Lord Young of Cookham. I welcome the focus on prevention in the NHS Five Year Forward View. However, I would like to mention a preventable cause of illness which the noble Lord, Lord Young, did not mention and which is linked to another of the Government’s stated objectives—that is, action on climate change.

Outside this building for the past two weeks, thousands of citizens have demanded urgent action on the climate change crisis. They did so while breathing air that has 50% more of the most dangerous small particulates than the WHO recommended maximum. In London, the average level of PM2.5 is 15 micrograms per cubic metre, while the WHO recommended limit is 10. Polluted air kills about 40,000 people a year. It causes respiratory and cardiovascular illness and affects the brain development of babies and young children. There is evidence that older people who breathe polluted air have a steeper reduction in cognition with advancing age compared with clean air breathers. Research from the University of Warwick shows a significant reduction in memory, equivalent to ageing 10 years, in those who breathe polluted air. Polluted air therefore attacks our thinking power as well as our health.

Tackling climate change from the health perspective is also the right thing to do for the planet. It is bad for your health and tackling it is the healthy option, but the forthcoming Environment Bill needs to go further. It promises legally binding limits on air pollution but we have not been told what those will be. Actually, we already have them within the EU but have continually failed to reach them. What is required, as called for by the All-Party Parliamentary Group on Air Pollution, is much more than painting the number plates of electric cars green; it is a phased reduction in the legal limit for PM2.5 to 15 by 2020, 12 by 2025 and 10 by 2030. This would provide the incentive to government and local councils to reduce car use and speed up the introduction of non-polluting electric and hydrogen-powered vehicles, while bringing forward the phasing out of those powered by fossil fuels to 2030. We need radical action on charging and refill infrastructure. This would help the UK meet its climate change commitments, which it is otherwise unlikely to do.

The proposed office of environmental protection also falls short. We need an independent body capable of rigorous scrutiny, with powers to investigate and gain access to data and the ability to monitor and force compliance and take Ministers to court if they fail to address these issues. We need these things for our health’s sake and our planet’s sake. So will the Government support the Private Members’ Bills introduced today by my noble friend Lord Tope and the noble Baroness, Lady Jones of Moulsecoomb? That would be a step in the right direction.

Restaurants: Calorie Labelling

Baroness Walmsley Excerpts

Tuesday 9th July 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her important question. She will know that we remain committed to delivering the actions we set out in chapter 2 of the childhood obesity plan, which included the consultation on calorie labelling in the out-of-home sector. We will publish it shortly. She will also know that our ability to introduce changes to the labelling system depends on EU legislation. We are committed to exploring whatever additional opportunities we can to have food labelling in the UK display world-leading, simple nutritional information, as well as information on origin and welfare standards. We will bring that forward as soon as possible.

[Baroness Walmsley (LD)]

My Lords, I was alarmed to read the Public Health England report about unacceptably high levels of sugar in baby foods, even some labelled as being healthy. What steps are the Government taking to ensure that such products give parents the information they need to make healthy choices for their children?

[Baroness Blackwood of North Oxford]

I know the noble Baroness has raised issues around baby food on several occasions. The reformulation programme taking place under the obesity plan takes account of sugar in a number of different products. So far, I do not think baby food has been one of these, but the Secretary of State has commissioned the CMO to urgently review what can be done to help the Government meet their ambition of halving childhood obesity by 2030. The report is due for publication by September and I will pass on the noble Baroness’s comments.

Food and Feed Hygiene and Safety (Miscellaneous Amendments) (EU Exit) Regulations 2019

Baroness Walmsley Excerpts

Tuesday 4th June 2019 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I congratulate the Minister on her explanation of this statutory instrument. We are of course back in the territory of whether there will a deal or no deal. Even more bizarrely, this will depend on the machinations of her party over the coming weeks and on who ends up as our Prime Minister. It is a bit surreal really, much like the parliamentary world we inhabit at the moment.

Earlier this year, as we approached the Brexit deadline of 29 March, we were regularly rushing through statutory instruments. It is just as well that the Prime Minister was able to secure a Brexit extension because, if we had left on 29 March, some of the so-called minor deficiencies that emerged with regard to food and feed safeguarding, which we are discussing today, might have turned out to be major quite quickly.

Crashing out of the EU means that the regulatory framework for food and feed, which has protected us in the UK for so many years, will cease to exist. I can see that the proposed amendments are critical to ensuring minimal disruption of food controls in the event that we leave the EU without a deal, and we on these Benches will support them. The changes seek to ensure a robust system of control which will underpin UK businesses’ ability to trade both domestically and internationally.

The first question I have concerns trichinella, a parasitic nematode worm which can be extremely serious and can cause disease in people who eat raw or undercooked meat from trichinella-infected domestic animals or game. I appreciate that this instrument provides assurance that testing requirements that ensure protection will continue after EU exit. However, is the Minister confident that we have enough capacity in this country to continue testing for that worm and its associated health risk? How quickly can the government put in place our own testing facilities? I would be grateful if the Minister could tell the House how much extra resource her department has allocated to make sure that we do not allow a loss of control in this area. I am aware that extra funding has been made available to the FSA to deal with Brexit, but the Minister could help the House by being specific about the amount of extra resource that would be available to ensure that those particular nematodes do not infect meat that might be imported into this country and eaten by people here. I am aware that the Minister in the Commons, Seema Kennedy, offered to write to my honourable friend Angela Eagle about this matter. Did she do so and can the letter be made available here?

The instrument states that facilities approved by EU member states would in future no longer be automatically approved for food imported from the UK. I repeat the question that my honourable friend Sharon Hodgson MP asked in the Commons: does the Minister know what impact that will have on supply and businesses? How long will the process be to approve facilities for food imported from the UK, and when will a list of approved facilities be available?

The instrument also includes provisions to set minimum charging rates for hygiene controls for fishery products by amending, as the noble Baroness said, the Fishery Products (Official Controls Charges) (England) Regulations 2007. Will the Minister outline what the charges will be and what impact any new set rates could have?

The Explanatory Memorandum for the statutory instrument states that functions currently undertaken by the European Commission in adopting some implementing regulations rendering applicable the controls on imported food will in future be the responsibility of the Secretary of State. Can the Minister provide information on how decisions on those controls will be made and managed? What will the arrangements be for collecting data monitoring the effectiveness of the regulations and for regularly reporting the findings? What bodies will be able to scrutinise performance and delivery? What assessment has been made of their capacity to take on that work, as my honourable friend Angela Eagle mentioned in the Commons?

Finally, what conversations has the Minister had with the devolved nations regarding this statutory instrument? Although the issues seem fairly technical, and potentially innocuous, they raise a few worries. This is about food safety, safety for consumers, consumer protection and food supply in general. Should we leave the EU European Union, a range of duties will transfer from where they have been carried out in the past for many years, in the EU, not just back to the UK but to four different bodies due to devolution, one of which is not even sitting at the moment because of what has been happening in Northern Ireland. So will the resources be available in the devolved authorities to cover these issues?

My honourable friend Angela Eagle said in the Commons:

“Despite the Minister’s attempts to engage with some of my questions, I am still not entirely sure whether this is irradiation of things such as collagen, which in specific instances is derived from animals for human consumption, or whether it is about more general irradiation of meat and vegetables that are for public consumption, which happens in the US”.—[Official Report, Commons, Third Delegated Legislation Committee, 13/5/19; col. 9.]


I agree that the answer the Minister in the Commons gave begged more questions, so let us have another go. That is probably appropriate today, when the President of the United States of America has made it clear that all our regulatory regimes will be on the table and up for negotiation, along, of course, with the NHS.

It is important to remember that the horsemeat scandal was not discovered by the enforcement processes in this country, but by testing in the Irish Republic. So we are right to be concerned that, post Brexit, things could go wrong due to weaknesses that have been created in our own enforcement system. I am looking for further reassurance from the Minister that the system we have, weakened by austerity and divided by devolution, will be robust enough to take on the extra duties that the Minister is adding through this statutory instrument.

[Baroness Walmsley (LD)]

My Lords, I too thank the Minister for outlining all the technical details of this SI. Of course, this instrument has been withdrawn from the Order Paper twice before. Some of the changes made since we originally saw it are small but crucial. We are lucky that they have been spotted, but that raises concerns for the industry that there may be others. Now that the leaving date has changed, are the Government planning on conducting additional scrutiny on the other SIs that are being rushed through this House to make sure that they are up to scratch? How do the Government intend to convey these changes to the relevant individuals and companies on whom they will impact?

I add my support to the question asked by the noble Baroness, Lady Thornton, about the capacity of the FSA. This is probably about the 16th time that we have asked the same question and we are still concerned about the capacity to replace all of the other measures.

Some of these changes reflect very recent EU law that has come into force, as the Minister mentioned, so what do the Government intend to do about any new EU law that might come into force between now and 31 October or whenever we happen to leave? Will these SI and the ones that preceded them have to be further amended if there are other changes to EU law?

The Minister mentioned that the system for minimum charging rates for hygiene controls of fishery products is somewhat out of date. Will the Government confirm whether they aim to change the pound-euro exchange rate from the 2008 level at which it is currently set? Although these charges, as we know, are rarely levied by local authorities, any change in the exchange rate, which could happen after Brexit, could have a big impact on the ability to pay of those against whom the charge is levied. We saw a big difference in the rate of the pound against the euro after the 2016 referendum, and the way in which we might, unfortunately, leave the EU, could have a similar serious effect on the exchange rate. What are the Government planning to do about those charges if there is such a big change in the exchange rate? Are they planning to bring it up to date from 10 or 11 years ago?

[Baroness Blackwood of North Oxford]

I thank the noble Baronesses for their important questions. We have been through a number of periods of scrutiny on FSA SIs between us, so I feel that we are old hands at this.

The noble Baronesses will know that leaving the EU does not change the FSA’s top priority, which is to ensure that UK food remains safe and is what it says it is. We are working hard with the FSA to ensure that the high standard of food and feed safety and consumer protection we enjoy in this country is maintained when the UK leaves the European Union. That is one of the reasons for this SI.

The noble Baroness is right to identify that this is one of the ways that we are keeping up to date with EU changes in legislation while we remain part of the European Union, but of course once we have left we will be responsible for identifying how we want to proceed and whether we want to introduce our own legislation and additional food safety standards which mirror those in the EU or whether we want to go further. That is a commitment—excuse me, I am having a Theresa May moment—that has been made before.

I shall touch first on the issue raised by the noble Baroness, Lady Thornton, at the end of her remarks about trade. I want to nail that one if I can. We have debated this before. The UK is committed to maintaining the high standards of food and feed safety which we currently enjoy. I shall repeat a line which has been used by No. 10. We have always been clear that we will not lower our food standards as part of a future trade agreement. From day one, we are committed to having a robust and effective regulatory regime in place which will mean that business can continue as normal. For most food and feed businesses there will be no change in how they are regulated and how they manage. Leaving the EU does not affect that, regardless of comments that may have been made this week.

Children: Gaming

Baroness Walmsley Excerpts

Thursday 23rd May 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

I thank my noble friend for his question. Hundreds of millions of people globally play videogames, and for the majority it is a positive recreational activity. He is right, however, that there is some evidence of a moderate correlation between gaming and depression and anxiety symptoms in young adults, and evidence that exposure to violent gaming can have an impact on sleep and mood. However, that is dependent on the nature and duration of gaming. We also support the WHO’s classification, which identifies addiction within the classification of diseases. The CMO said in her evidence review, however, that there is insufficient evidence to support a specific evidence-based guideline on screen time. That is why we support more applications to the NIHR for research so that we can have a better understanding of the impact of gaming on young people. We would encourage anyone who is concerned to contact their GP.

[Baroness Walmsley (LD)]

My Lords, as the noble Lord, Lord Brooke, said, this is about gaming, not gambling. Although some games can indeed be beneficial, some of them have covert elements of gambling in them such as loop boxes. Will the Minister assure the House that the PSHE curriculum in schools will cover elements of gambling, including those hidden in otherwise innocuous activities such as gaming? How do parents find out which are beneficial and which are the harmful ones?

[Baroness Blackwood of North Oxford]

My Lords, the noble Baroness is absolutely right, as ever, on this point. There is a challenge for parents and young people to be more educated and more critically engaged with online harms. The Online Harms White Paper is out for consultation until 1 July and I encourage all Members of this House to engage with that consultation. It is about setting clear responsibilities for tech companies to keep UK citizens safe but also about thinking about how teachers, parents and young people can get the best out of their engagement with the internet. To encourage the noble Baroness, our children and young people’s mental health Green Paper addresses these issues and we shall make sure that we drive that agenda forward.

NHS: Shortage of GPs and Nurses

Baroness Walmsley Excerpts

Wednesday 8th May 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

I thank the noble Lord for his Question and I echo his sentiments exactly in thanking GPs, nurses and all of our NHS workforce. Probably every noble Lord in this Chamber has a personal story of owing the NHS for personal service, as we do as a nation. That is exactly why the Government have put in a serious plan to address the challenges within the workforce. First, within the long-term plan we identified an increase in funding that is higher within general practice and community care than the wider increase in funding of £4.5 billion. Secondly, we have recruited the highest number of GP trainees ever. This is not swapping statistics, this is identifying the fact that we are being successful in recruiting into a challenging specialty. Thirdly, we are opening brand new medical schools to ensure that we have the capacity to increase training, while recognising that it takes time to grow a doctor. Fourthly, we are putting in place incentive programmes to make sure that the job is more attractive, so that we can retain those individuals.

Within the new general practice contract framework we have put funding in place for up to 20,000 more support and technical staff working in GP practices in order to relieve the pressure within that job. This will help bring down delays in getting appointments and make sure that the job is more attractive in itself. When it comes to nursing, we have put in place a pipeline, with new nursing associates and the new nursing degree apprenticeship, and we see this starting to pay off. So there is an improving picture, but there is still some way to go. We are making sure that we put in place a serious plan and we are determined to deliver on it.

[Baroness Walmsley (LD)]

My Lords, the Nuffield Trust has noted that there are fewer GPs per head in poorer areas than in wealthier areas. Health inequalities in this country are being made worse by some of the political decisions of this Government. Can the Minister say what steps the Government are taking to ensure that everyone has equal access to a GP, whatever their income and wherever they live?

Antimicrobial Resistance

Baroness Walmsley Excerpts

Thursday 2nd May 2019 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I too thank the noble Lord, Lord Lansley, for giving us the opportunity to talk about antimicrobial resistance, because, as we have heard, it is one of the world’s most difficult and dangerous health challenges. It could put back the clock and make many of the treatments which we take for granted, such as the surgery undergone by the noble Lord, Lord Crathorne, far too risky in future.

It is not often that you read a book by an eminent doctor whose findings not only scare you but had obviously scared them too. However, that is what I found when I recently read the book about AMR by the Chief Medical Officer, Professor Dame Sally Davies. Near the beginning of the book she says that the findings of the group of experts she brought together were simple: first, we are losing the battle against infectious diseases; secondly, bacteria are fighting back and becoming resistant to modern medicine; and, thirdly, in short, the drugs no longer work. She admitted to feeling rattled about that, and so am I. Therefore, I congratulate the Government on the latest iteration of their comprehensive plan to tackle AMR, and welcome the fact that the plan outlines actions to control AMR both within and beyond our borders. I also welcome the fact that the plan for the next five years has brought the four nations of the UK together, unlike the previous version.

One principle of the plan is reducing the need for using antimicrobials to limit the opportunity for microorganisms to evolve resistance to them. I will mention three ways of reducing the need for these medicines: immunising the population against the diseases that might require such treatment; tackling the spread of infection; strengthening the natural immunity of patients and supporting their general health so that they can fight off infections themselves.

Vaccines are of course the most effective preventive health tool in human history, and have been able to eradicate entire diseases such as smallpox. As the noble Baroness, Lady Greengross, mentioned, expanding the use of existing vaccines would have a major impact. For example, universal coverage of children by the pneumococcal vaccine would avert 11.4 million days of antibiotic use in children under five each year. However, we also need new vaccines, but no new class of vaccines has been discovered in decades.

The noble Lord, Lord Lansley, was absolutely right to focus on money. There are major financial barriers in the way of developing new antimicrobials. It is now five years since the Health and Social Care Committee in another place urged,

“tangible and rapid progress in this area within six months”.

However, as the House has heard, in the last few years, since discussions have been ongoing between the industry and the Government about the deterrent effect of the current funding model, three multinational pharmaceutical companies have left the market. Significant government investment is also needed in novel vaccine research, to tackle an increasingly urgent global problem.

Although the UK cannot rescue the situation alone, the unique nature of the NHS gives us the opportunity to demonstrate a new funding model that could work for both of these groups of pharmaceuticals and set an example to other countries. I was therefore pleased to see that the Government and the industry have agreed a new funding model for antimicrobial development and supply that will provide more stable income to the companies, while providing the NHS with novel antimicrobials which can be held in reserve by doctors for use when older, cheaper medicines no longer work because resistance to them has been developed. I understand that the new model will delink the payments made to companies from the volumes of antibiotics sold, basing the payment instead on a NICE-led assessment of the value of the medicines and supporting good stewardship.

When will the Minister be able to report on the timeline for the full implementation of this pilot scheme and how will the Government assess whether it has been a success? Will the new model also be used to fund the development of new vaccines, many of which are badly needed in countries that cannot afford to develop them themselves but which are often the source of infection outbreaks in this country?

Infections are spread around the population by many means, via water, food, air droplets and poor sanitation, and we are fortunate in this country on most of those issues. However, what should be most easily prevented are those infections acquired in healthcare settings. This is particularly dangerous because patients are at their most vulnerable and may have compromised immune systems. Healthcare-acquired infections are among the most serious modern public health problems worldwide and many are caused by antibiotic-resistant bacteria, so effective HAI management is vital to slowing the AMR crisis. It is therefore critical that the NHS puts in place system-wide processes, such as screening and surveillance programmes, and the highest possible level of hospital hygiene and sterile practice that can help tackle HAIs and reduce their incidence. The Government must also maintain their focus on HAIs to ensure that infection rates, which have been falling, do not start to rise again. Unfortunately, they have now plateaued.

Across the NHS, there is regional variation in hospital-acquired infection rates. According to freedom of information data, almost two-thirds of hospitals do not offer point-of-care testing, a tool that could help provide real-time information on patients for a range of infections. Only eight out of 50 trusts routinely carry out point-of-care testing for infections such as flu, and less than 10% of trusts test for a full range of infections, such as MRSA and others. Some trusts consistently appear among the best, and some consistently among the worst, for reported cases. Of course, one has to ask whether these trusts have better or worse reporting mechanisms, or whether they have more or fewer cases to deal with. But whatever the answer, can the Government assure me that the focus is still on getting these figures down? Personally, I would be very reluctant to go into a hospital with a poor record on this.

Optimising use—for which read “reducing unnecessary prescribing”—requires both public and medical education. Patients need to know that it is sometimes for their own benefit when their doctor tells them they do not need antibiotics but advises them instead to go home, rest and take plenty of fluids, and not to go to work or school and spread it around. On a system-wide basis we need to be able to report on the percentage of prescriptions supported by either a diagnostic test or a decision support tool. There is a target for this in the plan. Will the Minister say whether there are online learning packages and easily available diagnostic tools, so that GPs can be supported to make the optimum decisions about prescribing?

We should not ignore the potential of strengthening patients’ own ability to fight off infection without the use of antimicrobials. Malnutrition can reduce the body’s own defences, and it is a disgraceful fact that there is malnutrition among the poorer sections of the UK population today, particularly among children and older people. I have even heard of malnutrition among long-term hospital patients because of the poor quantity and/or quality of hospital food, or the fact that no attempt is made to ensure that the patient eats it. This factor cannot be ignored when considering how we can reduce the spread of disease. Will the Minister say what action is being taken to tackle malnutrition?

Another aspect of boosting natural immunity—mentioned, I think, by the noble Baroness, Lady Masham —is the role of microbiome; that is the 39 trillion microorganisms that occupy our bodies. Of course, some can be harmful, but the majority contribute to health. There is some evidence that a healthy, varied gut microbiota can have a beneficial effect on our immune system. Specific bacteria in the gut have been associated with immune development, and we know that germ-free mice have less well developed immune cells. Altered populations of bacteria are associated with a host of diseases, from allergy, asthma, autoimmunity and neurodegenerative diseases to obesity. However, we probably still do not fully understand which specific bacteria are important for health. A better understanding of the community of bacteria that affect our health is needed. This is a promising area of research, so will the Minister tell the House whether the Government are investing in research into the contribution the microbiome can make, particularly to immunity against infectious diseases?

NHS Mandate

Baroness Walmsley Excerpts

Thursday 25th April 2019 Lords Chamber

[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.

[Baroness Walmsley (LD)]

My Lords, I am very sorry that the Minister has been forced to give such an innocuous Answer on such a very important issue. We are awaiting not only the mandate but the workforce plan, and we have long awaited the social care Green Paper. Is the department still busy recruiting around the world to replace positions that are being vacated by staff from the EU—who are either going home or not coming here in the first place—or is there some other reason? I would have been much more reassured if the Answer had told us that the department is discussing with other departments across government the social determinants of health and how addressing those will help make the NHS much more sustainable in the near future. Can the Minister rescue this innocuous Answer by assuring the House that those discussions are taking place?

[Baroness Blackwood of North Oxford]

The noble Baroness is absolutely right that there is cross-departmental relevance to both the social care Green Paper and the workforce strategy. She will know that the long-term plan and the forthcoming Green Paper on social care have been developed in tandem. A number of reforms were already set out in the long-term plan, including the enhanced health and care homes model, which will of course involve MHCLG; the comprehensive model for personalised care, which will involve the personalised health budgets; and of course local health and care plans, which will simplify healthcare systems. We are looking forward to the Green Paper being published in full and I am sure that she will want to hold me to account on that in this Chamber. I look forward to that moment with great anticipation.

Of course, the workforce plan and HEE’s budget are also a matter for cross-departmental debate, as is the spending review, which is another reason why a lot of work is going into this. Again, it is important that this work is done to get it exactly right. The principles on which that work must be done are to consider multi-year funding plans for clinical training places based on the workforce requirements of the NHS going forward.

Access to Medicinal Cannabis

Baroness Walmsley Excerpts

Tuesday 9th April 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

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

[Baroness Walmsley (LD)]

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

[Baroness Blackwood of North Oxford]

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

Food Additives, Flavourings, Enzymes and Extraction Solvents (Amendment etc.) (EU Exit) Regulations 2019

Baroness Walmsley Excerpts

Tuesday 9th April 2019 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I too thank the Minister for repeating the information that has been debated already in another place. I share most of the concerns of the noble Baroness, Lady Wheeler, particularly those about the resourcing and training of the FSA and local authorities. In fact, I expressed those concerns in debates on every single SI in this group which were responded to either by the Minister or by the noble Baroness, Lady Manzoor, so I will not repeat them. However, I still have concerns about the fact that an organisation that has been so minimally resourced until now will take on such enormous responsibilities in the future.

We are now three days away from the current exit day from the European Union. Like the noble Lord, Lord Robertson, I have a birthday on Friday and I very much hope to have the best possible birthday present when we do not leave the European Union it would be the worst possible one if we do. However, the proximity to Friday is particularly relevant to this SI because of the delay in putting it before the House. It occurs to me that there will be a lag between possible exit on Friday and the coming into force of this instrument. What effect will that have?