Long-term Plan for the NHS

Baroness Walmsley Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord Hannay of Chiswick (CB)]

My Lords—

[Baroness Walmsley (LD)]

My Lords—

[Baroness Manzoor (Con)]

It is the turn of the Liberal Democrat Benches.

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[Baroness Walmsley]

My Lords, first, the Statement mentions £1.25 billion cash to cope with specific pension pressures. Is that because so many doctors are retiring early, and therefore drawing their pensions early, because of the pressures of the job? I know three GPs who are retiring far too early because of those pressures, so will the NHS be able to spend some of that money to relieve those pressures? Secondly, the Statement mentions that the Government want to prioritise prevention and that the NHS should get better at managing demand effectively. There are two factors that limit its ability to do that: social care has been mentioned by many noble Lords but I would also mention prevention. Can the Minister assure us that, when we get the spending review, the amount of money that goes to local authorities co-operating with the NHS on the prevention of ill health will not just be enough to make up for the cuts they have suffered over recent years but enough to really go forward and transform prevention measures?

[Lord O'Shaughnessy]

To answer the noble Baroness’s first question, I believe that changes in actuarial calculations were the driver of that change. However, it is a technical issue and I will write to her and place a copy of the letter in the Library so that other noble Lords can see the rationale for it. Regarding her question about public health funding, obviously it is not for me to make predictions about exactly what will be in the spending review, save to say again that there was a clear commitment in the Statement that we would not create further pressures for the NHS through the settlements delivered for social care and public health.

Education (Student Support) (Amendment) (No. 2) Regulations 2018

Baroness Walmsley Excerpts

Monday 21st May 2018 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, the huge pressure which the NHS is under is taking a massive toll on our nursing, midwifery and other health professionals. It has been estimated that the NHS in England has approximately 40,000 nursing vacancies, with a vacancy rate of over 10%. A similar rate applies to midwives, although the RCM estimates it to be higher, to reflect the number of babies being born. The other health professions covered by this regulation are similarly affected. More nurses and midwives are leaving the profession before retirement; one in three nurses is due to retire in the next 10 years. For various reasons, including Brexit, work pressures and the age profile of the nursing profession, the number of nurses and midwives on the NMC register at the end of March 2018 was less than that in March 2017 and significantly less than at the peak in March 2016.

The House of Commons Health and Social Care Committee inquiry found that the nursing workforce in England must be,

“expanded at scale and pace”,

and that,

“future projections of demand for nurses should be based on demographics and other demand factors, rather than on affordability”.

Given this, one would have thought that the Government would do all they could to support and encourage entry to these professions. Instead, they are doing the opposite, reflected in these regulations, by ploughing ahead with their plan to scrap bursaries for yet more students, despite knowing full well the disastrous consequences that will follow.

Two years ago, the Government scrapped the undergraduate bursary. The results were predictable. In 2016, before the abolition, there were more than 47,000 nursing applicants in England. In 2018, the figure fell to about 31,000—a fall of over 15,000. It is clear that this is the reason why we have seen the sharpest ever decline in nursing applications. I have no doubt that the Minister will say that the number of applications is less important than the number of acceptances. I disagree: I want nursing to be seen as a profession where there is hot competition for places because it is such an attractive profession to be in.

No doubt the Government will say that they have committed to create more training places for nurses. They certainly promised an extra 5,000 nursing places and said that nursing bursaries had to be scrapped to make that possible. What has been delivered is a mere 700 fewer students training to be nurses. It is worrying, too, that there has been such a huge drop-off in mature students applying—the extraordinary figure of 42%. The very people we need to apply, who have often brought up a family, are now being denied an opportunity to make a career in nursing or face the consequences of being forced into huge debt.

We know that postgraduate students in particular are more vulnerable to the introduction of fee loans: 64% of postgraduate healthcare students are aged over 25 compared to only 18% of students generally. Women are largely attracted to the healthcare postgraduate route and represent 80% of the course places. There is a higher percentage of ethnic minority students on postgraduate healthcare courses compared to the general population, and the Department for Education equality analysis clearly states that these groups are known to be more debt averse. So introducing loans is likely to undermine recruitment of this cohort and represents yet another missed opportunity to grow the nursing workforce at a time of severe shortage.

The Government claimed in the other place that raising the cap will unlock additional places, but it was the Government themselves who set the cap through their funding of Health Education England. They also say that they can fill some of the gap with nursing apprenticeships. They have promised 1,000 of them, yet only a handful have started the course. This shortfall is not the only problem with overreliance on apprenticeships. A nursing apprentice will take four years to become a registered nurse. Even if there were a miraculous surge in apprenticeships starting this summer, we would not see any qualified nurses on our wards until 2022. Contrast that with an undergraduate nursing course, which can take three years, or postgrad courses referred to in the regulations, which can take two years, which makes them the quickest way to tackle the shortfall in numbers.

Another solution the Government have come up with is nursing associates. But there is clear evidence that using support workers or trainees as replacements for qualified nurses has potentially disastrous consequences for care. I hope that the Minister will confirm that that is not the Government’s intention. The nursing associate is a support role and must not be used as a substitute for registered nurses. Research is clear that diluting and substituting the registered nursing workforce with nursing support workers has ill consequences for many patients.

In pushing ahead with this regulation, Ministers ignore their department’s impact assessment. The DfE’s assessment of the changes to the bursary said that it would disproportionately affect women and ethnic minority students, yet Ministers have pressed ahead. Then the department found that the change could make women, older students and students with lower incomes less likely to participate. Again, Ministers pressed ahead.

This is not just a matter of fairness or even just about the benefit of having a diverse working population. In fact, older nursing graduates, to take the nursing profession in particular, are more likely to stay longer in the NHS and are more likely to choose areas such as mental health or learning disability nursing, which are facing such severe staff shortages. Nearly two-thirds of postgraduate nursing students are over 25, more than a quarter are from minority ethnic groups and 80% are women, so the impact of today’s regulations will surely be even worse than the previous cuts.

I welcome the golden hellos to postgrad students in specific hard-to-recruit disciplines, but the Government need to do much more to financially support postgraduate students.

Even if the Government are determined to make the change, there are good reasons not to make it now. This policy would move postgraduate nursing students over to the main student finance system, which means dealing with the Student Loans Company. There is every reason to believe that that company may not be ready. In recent weeks, the Government have been dealing with an error made by the company that has led to 793 nurses being hit with unexpected demands to repay accidental overpayments they were unaware of. I do not know whether the Minister has seen the recent NAO report on the company, but that also gives great pause for thought about whether it is able to accept this new responsibility. It strikes me that, before embarking on these regulations, we have the flagship review of higher education. The Government could have allowed that review to take account of this matter, rather than going ahead with the change today.

My final point is about student finances in general, and the impact on the Government. How many postgraduate students affected by this policy will repay any or all of their additional loan? How is this financially sustainable? Or is it just another example of what the Treasury Select Committee called a “fiscal illusion”—in this case, a student financial system that allows the Government to pretend that they have made a saving when all they are doing is passing the Bill to the next generation?

It is little wonder that the devolved nations have retained the NHS bursary system. We in England should do the same. I beg to move.

[Baroness Walmsley (LD)]

My Lords, like the noble Lord, Lord Hunt of Kings Heath, we, too, oppose the introduction of these regulations—and for very similar reasons. It always makes sense to make policy based on evidence and on the advice of experts. This is what the Government have failed to do in relation to the funding of student nurses. The removal of the bursaries for undergraduate nurses has already considerably reduced the number of applicants, and the number of those taking up a place was 705 lower last year than the year before. Given the 40,000 nurse vacancies that the noble Lord mentioned, this is a serious matter for patient safety, as pointed out by the Care Quality Commission. I accept that these are only one year’s figures, but I believe that, before upsetting the apple cart even further, the Government should postpone removing bursaries from postgraduate nurse trainees and other important groups until we have clear evidence of the effect on the number of undergraduate student nurses.

If we want to increase the number of registered nurses quickly, which we need to do, it makes more sense to support the two-year postgraduate route, not put it at risk by removing those bursaries, too—because this is the quickest way to get more nurses. Most suppliers of the two-year courses indicate that capacity could be increased by 50% given the right financial support, yet the Government are planning to deter applicants by removing the bursary. This does not make sense. Instead, the Government are focusing on the two four-year routes into nursing, yet the apprenticeship route is not providing the expected 1,000 extra nurses per year. The most recent data tells us that there are only 30 apprentice nurses—hardly a success. Will the Government look into the barriers that are preventing NHS employers taking on apprentices? It could be the 60% cut in funding for further professional development, which has affected the number of those who would like to become training assessors and mentors for student nurses and apprentices.

Nursing associates have a role both as assistants to registered nurses and as users of an alternative four-year route into nursing—but, again, it takes a long time and these associates, as the noble Lord, Lord Hunt, said, should not while training ever be seen as substitutes for fully qualified nurses. So why are the Government planning to deter applicants for the rapid postgraduate route, where 64% are over 25, where they are predominantly women and where they are more diverse than the general student population? In a career such as nursing it would be advantageous to attract people with a little more life experience than the average 18 year-old.

Also, we know that older women and ethnic minority students are more debt averse, as well as already having a student debt of up to £50,000 from their first degree. Therefore, it is vital to look at how this fast route into nursing could be supported. The RCN tells us that, if the fees were paid and a modest bursary towards living costs provided, the total would be less than the average annual premium paid by trusts over a single year for a full-time agency nurse. This is short-termism of the worst kind.

While the Government carry out their review of post-18 education, they might benefit from looking at the measures introduced in Wales by Kirsty Williams AM, the Liberal Democrat Minister in the Welsh Government responsible for medical education. Her conversations with students revealed that the main concern and deterrent was not fees but living costs. Therefore, she has introduced the equivalent of the minimum wage for students during their course. This method of student funding should be carefully considered by the Government while carrying out their review, particularly for nursing students, who have more contact time than other students because of their clinical placement and therefore less time to get a part-time job to support themselves. Will the Government please consider this sensible idea?

The House of Commons Select Committee on Health and Social Care stated that the nursing workforce should be expanded at scale and pace to avoid dangerous levels of vacancies. It should be based on need and demand rather than affordability. It is up to the Government to say how the money will be raised, but from these Benches we recommend some sort of hypothecated taxation or a reformed national insurance scheme which is truly progressive and demonstrates intergenerational fairness. The Liberal Democrats are also in favour of restoring the bursaries for undergraduate student nurses and we are against these new regulations, which would remove the bursary from postgraduate nursing students and other important health professional courses.

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[Lord O'Shaughnessy]

I do not want to get into an argument about funny money and magic money trees, but it is worth pointing out that the proposal to treble student fees came from the Browne review, which was instigated by a Labour Government, and indeed the 2010 Labour manifesto committed a future Labour Government to implementing the findings of that review.

[Baroness Walmsley]

I would add that the Browne recommendations had no cap at all.

[Lord Hunt of Kings Heath]

My Lords, I would pray in aid my noble friend Lord Adonis, who sadly is not here tonight, and take the Minister back to the original intent of the loans that we introduced.

The Minister does not seem to have responded at all to the issue that, essentially, we are transferring this debt to future generations. At some point, the fact that so little of the loans is being paid back will have to be confronted. The Minister justifies increasing the number of places now on the basis that at some time in the future some Government are going to be faced with a massive problem. So not only are we discouraging some of the most important people that we want from coming into the profession, but we are also engaging in the most extraordinary financial trickery to justify current expenditure.

The Minister mentioned apprenticeships and associates. Of course we should welcome apprenticeships, and I welcome the associate profession, which is a good thing. However, the problem is that we know what the health service gets up to. We know that directors of nurses do not have as much influence on boards as they need, and that NHS trusts up and down the country will substitute associates for qualified general nurses whenever they can. Given the debacle of the whole apprenticeship approach, in putting all our eggs into that basket we are very much risking the future of this profession.

My noble friend Lord Puttnam talked about the problem that it takes a long time to recover from a situation of drastic shortage, and my noble friend Lord Clark talked about some of the implications. When you see a car crash about to happen, you usually attempt to stop it. I see this policy as putting the foot on the accelerator, leading to an inevitable crisis.

However, this was debated in the other place. I see no purpose in prolonging the debate. I hope that, under the auspices of the review of student finance, the Government will start to think again. I beg leave to withdraw the Motion.

Children: Obesity

Baroness Walmsley Excerpts

Thursday 10th May 2018 Lords Chamber

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for her acknowledgement of that important step forward in recruiting nurses to hard-to-recruit areas. That is important because we want more mental health, learning disability and district nurses in the future. They have an important role to play in schools. If I may say so, the noble Baroness is slightly underplaying the work that schools are already doing in this area. We have talked about the Daily Mile programme, which is going very well, with 900 schools in England adopting it. Learning about food, healthy eating and nutrition is a compulsory part of the curriculum in key stages 1, 2 and 3. However, I agree that there is always a need to do more.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that when you cook your meals from scratch, you know what is in them and are more likely to stay healthy? Can he assure me that children learn to cook in schools, not just the theory of nutrition? Will he also join me in encouraging the BBC to produce a cookery programme aimed at children?

[Lord O'Shaughnessy]

I am turning into the commissioner of children’s programming. I am trying to remember—I think that there is actually a CBBC programme that encourages children to cook. Its name has gone completely out of my mind but it was popular with my children. The noble Baroness raises an important point. Children learn to cook in primary schools, most of which have some sort of kit that allows them to do that. It is critical for them to understand that food does not just come from packets or shops but can be created by hand—and enjoyably, too.

The Long-term Sustainability of the NHS and Adult Social Care

Baroness Walmsley Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, as the brilliant Select Committee report makes clear, sustainability of health and social care is mainly achieved by a match between demand and available resources. Whatever funding solution the Government eventually propose, there is always likely to be pressure on money, so two approaches are necessary—to reduce demand and to work more cost-effectively. As my noble friend Lord Willis said, healthcare costs cannot be considered in isolation. Social care and the wider determinants of health, from public health, prevention, education and housing must be factored in. So the issue is much wider than the NHS, although its role in helping to reduce demand by prevention of ill health and developing new models of care is crucial.

The committee was quite right in its recommendation 19: it is essential that social care and health are properly integrated from top to bottom as they are interdependent —and Salford has proved that that works. Social care thresholds are rising but the need remains and is often displaced to the more expensive NHS. That is not clever. As the population ages, and as technology and infrastructure develop and appreciate, funding levels need to be adjusted accordingly. However, it is vital that we get a grip on rising demand, which is not caused just by our ageing population but by our failure to prevent preventable diseases. An eight year-old child wrote to me the other day about the link between child obesity and junk food; he said that we were not preventing preventable diseases, that it was not hard to prevent them and yet we were not doing so, and it was very sad. Well, indeed, it is very sad. The Select Committee was forced to write:

“We are of the firm opinion that continued cuts to the public health budget are not only short-sighted but counter-productive”.


Hear, hear. I strongly support its recommendation 30 that these funds should be restored.

Unless we put more effort into prevention of ill health, the burden of disease and demand for services will continue to rise. The committee pointed out that 89% of deaths in the UK are caused by cardiovascular disease, cancer, respiratory disease and diabetes. Many of these diseases are caused by lifestyle choices, such as poor diet and sedentary lifestyles, alcohol abuse and smoking. In recommendation 29, the committee proposes a nationwide campaign to highlight the problems caused by obesity, particularly among children. I hope that my speech on child obesity last week indicated how much I support that. I welcome the fact that the chef, Hugh Fearnley-Whittingstall, has already started that nationwide campaign with one city, Newcastle-upon-Tyne, as the noble Lord, Lord Rea, pointed out.

Many diseases are also caused by the social determinants of health, poverty, poor housing and poor air quality, which can shorten life in poor areas by as much as seven years, according to Professor Michael Marmot. This shocking health inequality is not social justice and must be addressed.

The five-year forward view called for a radical upgrade in prevention and public health and yet, in recent years, as many have said, we have seen a 30% cut in spending on these areas. Hard-pressed local authorities cannot subsidise public health. The Select Committee makes it very clear that this must change. What are the Government going to do about it?

People must take some responsibility for their own lifestyle choices, but we must not continue to rely on the NHS to fix it when we make the wrong choices. To make the right choices, we need information and help from public services that have now gone. However, people are not responsible for finding themselves in poverty or for living in areas with terrible air quality and poor access to healthy foods, as Hugh Fearnley-Whittingstall discovered.

The Government cannot rely on food retailers to take responsibility for this, but they do have a role to play. I welcome the recent initiative by Waitrose to introduce healthy eating specialist advisers in some stores—although it must be pointed out that Waitrose stores are not usually to be found in the poorest areas of the country. I congratulate those food manufacturers which have already reformulated their products to reduce sugar, salt and saturated fat and to reduce portion sizes but, as the noble Lord, Lord Rea, said, there is still a very long way to go. What plans do the Government have to learn from the response of sugary drink manufacturers to the threat of the mandatory sugar tax?

There is also enormous potential for technology and innovative treatments. The committee’s recommendations 24 to 28 encourage this, which I support. Where I live in Wales, we do not have access to some of the new tests and treatments available to noble Lords who live elsewhere in the country. It is a postcode lottery, which is the responsibility of the Welsh Labour Government. I say to the noble Baroness, Lady Meacher, that we are also about to lose the only GP practice in our large village of 4,000 people. Although I have often had to dial 50 times before getting through to make an appointment, I will miss it. I hope that my husband and I will not find ourselves sitting for over four hours in the A&E department of our local hospital as a result of the withdrawal of our valued primary care, so I agree with the committee’s recommendation for a review of the business model of primary care.

Children and Young People: Obesity

Baroness Walmsley Excerpts

Tuesday 17th April 2018 Lords Chamber

Asked by

[Baroness Walmsley]

To ask Her Majesty’s Government what steps they are taking to address obesity among children and young people.

[Baroness Walmsley (LD)]

My Lords, we have a childhood obesity epidemic in this country, with disadvantaged children significantly more likely to be affected. Nearly one in four children is overweight or obese in their first year of primary school, rising to more than one in three by the time they leave. Overweight children are more likely to become overweight adults, leading to heart disease, cancer, diabetes and stroke. Issues related to diabetes are a strain on the economy and on the NHS, so we need to address this at the earliest possible opportunity, while people are young—hence this debate.

Out of the mouths of babes and sucklings come truth and wisdom, so I thought that perhaps we should hear from the children themselves. It so happens that I recently received 30 letters from children at St Joseph’s Catholic Primary School in Burnham-on-Sea. These eight and nine year-olds are very aware of the dangers of obesity, such as heart disease and diabetes—although they did not mention cancer, even though 5% of cancers are thought to have a dietary link. They are not alone, since 85% of the population is also unaware of that link.

The children have been looking into the advertising of junk food on TV and wrote to ask me to do something about it. They said that 23 children out of their class of 30 had seen more junk food adverts than healthy food adverts. Here is what William had to say:

“As everyone knows fat is bad for you and surely our kids are being poisoned by too much. Firstly we should get good foods on our plates. Secondly we need to get bad foods off our plates. Thirdly fatty foods can block your arteries. I would draw your attention to the fact that 28 out of 30 children said adverts make us want to buy garbage. Therefore we must not let unwholesome adverts on TV every day, just on Mondays and Saturdays and moreover we must show more Fit4Life adverts. My evidence to support this is only 10 out of 30 kids have seen Fit4Life adverts which is not good. In summary we must stop this advertising problem. My final point is that you are responsible”.


George agreed, but he let out a little secret:

“Isn’t it the case that people like the taste of fat and if you keep eating junk you will get heart disease? Some eat a midnight snack under the bed, not often but it is probably junk food”.


Jared was concerned about the NHS. He said:

“Surely we can help the NHS. They are having too many customers”.


He must have read the 2016 report from the Food Foundation, which claimed that the current diet-driven crisis is crippling the NHS. The report said that NHS costs associated with being overweight or obese are £6.1 billion every year and £27 billion for the wider economy.

Ryan thinks you should have a balanced diet. He said:

“My view is balance. Get rid of some junk food but not all junk food because some people like it, including me”.


The new soft drinks industry levy, commonly known as the sugar tax, came into force recently, and that is a very good thing—although the children are not fooled. They have noticed that it is limited to sugary drinks. For example, Brac said:

“I would draw your attention to hidden sugars which are found in cereal, yoghurt, bread, smoothies and pizza”.


No fool, Brac.

So, on the children’s behalf, can I ask the Minister whether the Government plan to do anything about all the other hidden sugars in our food? I must say it is very heartening to hear that so many popular drinks have been reformulated, although I am sure they would not have done it without the levy. So it is important to monitor the effects of the sugar tax, and I hope the Minister will say how they intend to do that. Will he also tell us where the money is to be spent and whether local authorities, which now have the responsibility for public health, will have a say in the matter?

The Advertising Standards Authority’s Committee of Advertising Practice is about to carry out a review of whether the rules on advertising junk food during children’s TV programmes and on non-broadcast media are right. The children and I think the rules need changing, so I hope the reviewers will take notice of their opinion. For example, Emma said:

“In my opinion adverts about junk food are taking over and I can’t help noticing that they mostly do it when children are around. Clearly people are falling for things like, if you eat these delicious golden chicken nuggets it will make you happy and if you drink this Cola, you and your brother will get along forever”.


But Lillia was not taken in. She said:

“Bad food makes you fat and ill and in the end you just die”.


Manley agreed. He said:

“Don’t eat junk. It could give you a very bad tummy ache”.


Joshua had a solution. He said:

“Isn’t it clear preventable diseases aren’t being prevented? It’s not hard to prevent them yet we don’t. It’s quite sad don’t you think?”.


He wants cheaper fruit and vegetables. The Food Foundation agrees. It recommends:

“Subsidies that favour healthy food over unhealthy food”.


The ASA said in its briefing to us at half past two this afternoon:

“Currently, the evidence shows that advertising has only a modest effect on children’s food preferences and that there are multiple and complex factors, beyond advertising, that are instrumental in childhood obesity.”


The causes are indeed complex but the children of St Joseph’s and many other experts do not agree that advertising has only a modest effect on children’s food preferences. Their letters refer to the large number of junk food adverts on TV programmes—in “family time”, not just children’s programmes—but they do agree that there are other factors. Holly says:

“Surely the Government can make a law saying there should be a limit of junk food adverts”.


But she realises that it is not just about what you eat; keeping fit is also part of the solution, and it is fun. Tommy agreed. He wants more PE lessons.

Finbar described children’s sedentary lifestyles. He said:

“It seems to me that people are starting to get more lazier by the day. As I see it people finish school or work, go home then walk to their TV or games console. And might even have their dinner there”.


Ukactive, chaired by our noble friend Lady Grey-Thompson, promotes physical activity for children. It told me that half of all seven year-olds are failing to achieve the recommended 60 minutes of physical activity per day. NHS research in 2015 found that one in five children did no sport or physical activity at school. It would help schools to plan if the Government were clearer about their long-term plans for the primary PE and sport premium. This might be the responsibility of the Department for Education, but could the Minister from the health department enlighten us? As Finbar said, physical inactivity is a major cause of childhood obesity.

The children want to know what we are going to do about it. Cancer Research UK proposes a 9 pm watershed on TV advertising of junk food. This does not require legislation; Ofcom could be instructed to act. Will the Minister comment on that? It is a decade since Ofcom’s restrictions came into effect, and in that time viewing habits have drastically changed. Evening and family programmes, shown between 7 pm and 9 pm, are now most frequently watched by children and young people, yet they are not covered by existing regulations unless the advertisement is directly aimed at children. It seems that current rules are no longer fit for purpose. The Obesity Health Alliance found that more than half of food and drink adverts shown during family viewing would be banned on children’s TV under current rules.

Your Lordships might wonder whether there is any evidence that restricting the marketing of junk food could help in the fight against childhood obesity. Well, I have good news. There is evidence from Quebec that a ban on advertising junk food to children can work. Its strict rules since 1980 have resulted in a much lower level of child obesity there than in any other part of Canada. Will the Minister look at this evidence and act on it? Given that Public Health England advised the Government to include further advertising restrictions in the 2016 child obesity plan, perhaps the Minister will explain why the Government did not take its advice. Could he now tell the House whether they have seen the error of their ways? If so, I will be delighted to tell the children of St Joseph’s.

Brexit: Health and Welfare

Baroness Walmsley Excerpts

Thursday 29th March 2018 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this has been a very well-informed debate, led by my noble friend Lady Brinton with her excellent and wide-ranging speech, on which I congratulate her heartily. There have been some excellent and moving speeches from across the House. I hope others will forgive me if I say how much I support the passionate and robust comments of the noble Lord, Lord Balfe.

As ever in your Lordships’ House, we have covered the ground very thoroughly. My noble friend Lady Brinton started us off by expressing her concerns about procurement and the need to protect our NHS from United States predation. We heard worries about the levels of staffing in both health and social care, and particularly the effects on some of our most vulnerable citizens of the loss of care workers from the EU. We heard about the loss of the EMA and its consequences for medicines regulation and for the access of UK patients to cutting-edge medicines. We heard concerns about clinical trials and the availability of clinical isotopes if we leave Euratom. We heard concerns about the recognition of qualifications; about research; about medical treatment across the Irish border; about data sharing; about health inequality; about reciprocal parking for disabled drivers; and about mental health. Lastly, from my noble friend Lady Tyler we heard a welcome, which I endorse, for the Prime Minister’s recognition at last that we need a long-term funding settlement for the NHS.

For myself, I would like to mention two issues that have been mentioned but not dwelt upon. The first is my concern that, if we leave the EU, we will no longer be part of the European Centre for Disease Prevention and Control, the ECDC, and have a seat at its table, currently occupied by Professor Dame Sally Davies, the Chief Medical Officer. The ECDC is an EU agency aimed at strengthening Europe’s defences against infectious diseases. It works in partnership with national health protection bodies across Europe to strengthen and develop continent-wide disease surveillance and early-warning systems. The ECDC pools Europe’s health knowledge to develop authoritative scientific opinion about the risks posed by current and emerging infectious diseases. It provides the NHS with evidence for effective decision-making, helps to strengthen our public health system and supports our response to public health threats. It does so through surveillance, epidemic intelligence, scientific advice, microbiology, preparedness, public health training, international relations and health communication. Its programmes cover a number of important issues that have been debated in your Lordships’ House over the past couple of years, including: antimicrobial resistance and healthcare-associated infections; emerging and vector-borne diseases; HIV; influenza; TB; and vaccine-preventable diseases. All in all, the ECDC monitors 52 communicable diseases.

If we no longer have access to these services after Brexit, we will suffer when, for example, there is a flu epidemic or pandemic and vaccines or other specific treatment need to be rationed across the EU. This is almost inevitable, as it is not possible with current technology for vaccine production to be scaled up fast enough since we need to know the specific flu mutation that we are dealing with before we can start manufacture. The ECDC will be driving who gets what, as it will be the conduit to the World Health Organization for the EU; the UK will be a single nation at the back of the queue, as we will be with new medicines licensing and access. What action have the UK Government taken to ensure that UK patients do not suffer because of our exit from the ECDC?

My second issue is that of food safety. I am sure that all noble Lords agree that the safety of our food is an important element in enabling our citizens to be healthy. In order to ensure safe food, our food producers need to practise the highest possible standards of hygiene, which most of them do, and our consumers need the best possible information. It is because of this that scandals such as 2 Sisters, Muscle Foods, DB Foods and Fairfax Meadow are relatively rare. It is also because of this that British food producers are currently able to sell their goods in large quantities across Europe and the rest of the world. Indeed, one claim the Government make about the potential benefits of Brexit is that British food producers will be able to sell more, thus benefiting our economy. We shall see.

There does not seem to be much emphasis on food and health in current government thinking. The agriculture Command Paper Health and Harmony, which came from the Environment Secretary, makes little reference to food apart from the issue of pesticide residues. The fisheries paper focuses on maximum sustainable yields—again, nothing about health. The focus seems to be more on cheap food than on food standards. But the British people want decent, affordable, sustainable healthy food, not a race to the bottom. I am concerned that this is not the direction in which we are going. I certainly do not think we should be opening our doors to a lot of foods from the United States, where its need to export large amounts of corn syrup means that sugars are found in the most surprising foods. For example, breast milk substitute in the United States can contain any kind of sugar in any amounts. We do not want that here.

Let us look at how our food industry standards are currently maintained. Currently, they must be up to the standards of the European Food Safety Authority, controlled by the European Commission. In the UK, the regulator is the Food Standards Agency, but it relies heavily on local authority environmental health officers and trading standards officers. I expect that the Government will say that the UK food supply is safe and that we are currently aligned with EU standards and that that will continue, so what is the problem? The problem is this. Between 2012 and 2017, the FSA’s budget was cut by 23% and the number of samples taken for testing by EHOs fell by 22%, so resources, including local authority funding of EHOs, are already stretched.

On top of that, Ministers have insisted that the FSA makes even greater savings, as a result of which last year it obligingly published a document entitled Regulating Our Future: Why Food Regulation Needs to Change and How We Are Going to Do It. I have just read a critique of this document by a collaboration of academics from the University of Sussex and City, University of London. I have scarcely ever read such a scathing academic study. The authors have the grace to support the proposal for mandatory registration of food business operators. They also support demands by environmental health officers that they should have the power to refuse registration to,

“FBOs that cannot demonstrate they can produce food that is safe and honestly labelled”.

However, the rest of the report is strongly critical, in particular of the proposal that inspection of FBOs should in future be outsourced—and not just outsourced. The proposal is that the food producer itself should contract a third party to inspect it on a basis it thinks is right at an agreed frequency and decide whether the inspection is notified—talk about marking your own homework. The fear is that the food producer will go for the cheapest option, which is unlikely to be the most rigorous, and our food safety will be affected. The other worry is about access to information—and the list goes on.

I do not think that this proposal from the FSA will give confidence to the European Commission or the European Food Standards Agency, in which case UK FBOs will have great difficulty selling their produce to either the EU or other countries, given that all over the world countries are moving to EU standards so that they have only one set to deal with. Add to all that the fact that the majority of vets contracted to supervise abattoirs and meat-cutting plants were recruited by the FSA’s outsourcing contractor from non-UK EU countries and you have a recipe for disaster in UK food safety.

This is one of the issues that the Government need to take extremely seriously when they are negotiating our exit from the EU. We need some confidence that the safety of our food, which has such a big effect on our health, will be taken into account by the Government.

Nurses: Training

Baroness Walmsley Excerpts

Wednesday 7th March 2018 Lords Chamber

[Lord O'Shaughnessy]

I thank my noble friend for highlighting that important issue. A very stringent language test is imposed by the Nursing and Midwifery Council—indeed, it is perhaps so stringent that it has excluded some nurses who are perfectly capable of practising in this country. A review of that is going on at the moment to make sure that a proper line is drawn—ensuring professional competence, including in technical language, while not excluding people who would be perfectly capable of practising well in this country.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that the vacancy rate for nurses in social care settings has doubled over the last four years? Given the other pressures on nursing homes, will the Government take specific action—perhaps grants for placements—to relieve this problem, which the NAO has described as dangerous?

[Lord O'Shaughnessy]

The noble Baroness has highlighted an important issue, which is the number of nurses in social care. I recognise that to be a problem, as does the department. A specific social care workforce consultation will get under way and is linked to the overall draft workforce plan that Health Education England has published. This is something that we are looking at. We can solve it to some extent by increasing the overall number of nurses, but we need to find ways of attracting them into the social care profession.

NHS: Cancer Treatments

Baroness Walmsley Excerpts

Thursday 25th January 2018 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this has been a unique, moving and effective debate. I am proud to be able to support the demands of the courageous noble Baroness, Lady Jowell.

In my three minutes I want to focus on two of her demands: early diagnosis and patient rights. Public Health England says:

“Diagnosing cancer earlier is one of the most important ways to improve cancer survival and we know that those patients who have their cancer diagnosed as an emergency have poorer outcomes”.


That is why new screening and diagnostic methods must be made available quickly.

In fact, I am standing here because of screening. I say to the noble Lord, Lord Turnberg, that I have had two as well; perhaps we should start a club. That shows how far we have come, does it not? Screening does not merely diagnose disease but can sometimes predict the risk of it through identifying gene mutations, as we have heard. Genomic screening can also contribute to treatment decisions by predicting how the tumour will respond to chemotherapy. That can avoid chemotherapy for those patients who will not benefit from it.

Diagnoses of colorectal cancer through the national bowel screening programme remain under 10%. This effective early diagnostic tool is not being used widely enough. Is that because CCGs are not offering the screening, or is it because people are not returning the samples? What are the Government doing to improve those figures?

I agree with the noble Baroness, Lady Jowell, that patients should have a great deal more say in the risks that they are prepared to take, and that adaptive trials should be allowed where they could help. I will not repeat many of the cancer-related examples that we are discussing today, but I shall give the House a non-cancer example of where the system is preventing a patient from receiving medicines that have already been shown to work, to illustrate that the problems that the noble Baroness has identified go wider than cancer.

A small boy, whom I will call A, has rare and serious epilepsy. He was treated, at great expense to the NHS, with powerful pharmaceutical drugs to stop his fits, although some of them were not even licensed for use on children. His condition did not improve and the doctors admitted the drugs could damage his vital organs and shorten his life. His parents heard of a similar case in Holland where a child was being treated successfully with cannabis-based medicines, which were licensed there.

Child A has now been receiving cannabis treatment in The Hague with enormous success. His doctor here is convinced of the safety and efficacy of these medicines, which are not licensed here, but is frightened to treat him with them because he is afraid that the GMC will strike him off. The family can no longer afford to remain in The Hague, yet the Home Office tells me that it will not grant a special licence for the treatment in the UK. This child could die of his fits. His parents would agree in a heartbeat for him to receive the medicines here, even though they are unlicensed. They know the risk is small and the benefits huge. They should have the right to make that decision for their child, just as the cancer patients mentioned by the noble Baroness should have the right to make decisions about risks and about their own treatment. What is the Minister going to do about that?

NHS: EEA Doctors

Baroness Walmsley Excerpts

Tuesday 12th December 2017 Lords Chamber

Asked by

[Baroness Walmsley]

To ask Her Majesty’s Government what assessment they have made of the number of doctors from European Economic Area states working in the United Kingdom who may be planning to leave the NHS after the United Kingdom’s withdrawal from the European Union.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, the Government value the contribution of all European Union staff working across the NHS and social care systems immensely. We have set out a clear pathway to permanent residency for these EU citizens. According to the latest NHS digital data, there are now more non-UK EU doctors working in the NHS than ever before, with almost 500 more since 30 June 2016.

[Baroness Walmsley (LD)]

My Lords, according to the BMA, almost half of EEA doctors are considering leaving the UK and one in five has already made plans to do so. Given that it takes 13 years to train a consultant, what is the Minister doing to fill these gaps in the short term? Is he aware that there are numerous doctors from around the world already resident in the UK but whose qualifications fall short of what is required by the NHS? They would dearly love to be able to upgrade their qualifications and help us to fill the gap that is going to be left by the Tory Brexit, but there is no organisation that will advise and support them to improve their qualifications. What will the Minister do about that?

[Lord O'Shaughnessy]

I recognise that, as the noble Baroness pointed out, there has been uncertainty. That is why I am sure that the entire House will welcome the agreement reached last Friday to provide that certainty, and I encourage all noble Lords to look at and circulate the letter written by the Prime Minister to EU citizens explaining how much we value them, how much we want them to stay and how we have now agreed with the EU a process for doing that. The noble Baroness will be interested to know, as I am sure will other noble Lords, that there were 470 more EU doctors working in the NHS in June 2017 compared to June the year before—so, happily, we have not seen the exodus that so many people have warned about. We need to grow more of our own in the future, of course, and there are 1,500 training places for doctors coming on stream in September 2019, but I shall certainly look at the issue that she raises about providing opportunities for doctors—not least refugees; that issue has been raised with me—to upgrade their qualifications so that they can serve in the NHS.

NHS: Staff

Baroness Walmsley Excerpts

Thursday 30th November 2017 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I thank the noble Lord, Lord Clark of Windermere, for bringing forward the debate today. It is high time that we debated the fiscal issues in relation to health.

Although it is always nice to see the noble Lord, Lord O’Shaughnessy, answering a debate, I fear he is the wrong Minister for this one. Indeed, I think there should be a whole row of Ministers sitting on the Government Front Bench today, led by a Minister from the Treasury. Here is the reason. Noble Lords who know me will recall that my favourite word in health debates is “prevention”. Without prevention of a great deal of the country’s ill health, of which we are perfectly capable, the cost burden of preventable diseases will bring the NHS to its knees. Our hard-pressed health and care workers will never be able to work hard enough. My party’s policy, for the moment, is to add one penny in the pound on income tax for health and social care, while continuing to take lower-paid people out of tax altogether by raising the personal allowance. However, while this would provide the NHS and social care with what they need for the moment, in the long term, this will not be enough if we carry on the way we are going.

I am a great believer in evidence-based policy and also a great admirer of Professor Sir Michael Marmot and his rigorous work on health inequalities and the social determinants of health. That is why I said what I did about the Minister being the wrong person to answer this debate. If you want to lead a healthy life, all the evidence shows that you need to be conceived and born to a family that is comfortably off. The Marmot indicators show very clearly that poverty and deprivation are the clearest indicators pointing to poor health. So what are the factors that contribute to this—those things known as the social determinants of health? Of course, they are low income; poor housing; low educational attainment, leading to lack of well-paid work; poor air quality; poor access to the cultural activities that contribute to our well-being and mental health; and poor access to the healthy food, help and advice that help us make the right choices for our own health.

So until we get a truly progressive tax system that taxes poor people less than rich people, until we stop subsidising the fossil fuels that pollute our air and warm our planet, until we train a highly skilled workforce and until we start building affordable well-insulated homes for poor people, we will never iron out the major health problems that keep our doctors and nurses far too busy. That is why we should have a Treasury Minister leading a team of Ministers from transport, housing, education, DWP, DCMS, DCLG, BEIS, Defra and all the other acronyms. Until we get a whole-government approach to the health of the nation, we will never solve the problems of health and social care. So as the noble Lord, Lord Clark, has rightly identified, fiscal policy is a powerful tool in this battle. I would like to hear the Minister say that the Prime Minister will show a bit of leadership on this and set up a powerful Cabinet sub-committee with teeth, which will be able to hold all the other departments to account on their contribution to the health of the nation. Until I hear about some mechanism of that sort, I fear that the Marmot indicators will never shift.

In addition to that, we politicians need to put our heads together. I fear that the Government’s failure to heed the calls of my right honourable friend Norman Lamb MP and others to put together a cross-party commission on a sustainable health and care service is very wrongheaded. Good-quality health and social care are things that people care about and vote about, and they depend very much on the welfare of staff. So I would have thought that any sensible Government would prefer to bring in all points of view to find the answers to a problem that has been growing for years, as the noble Lord, Lord Clark, just said. And no, the Government do not have all the answers. This House’s Select Committee, led by the noble Lord, Lord Patel, had many of the answers, but they nearly all involved money, yet what did we get in the recent Budget for an NHS that needed more than £4 billion extra and a care system that needed £2.6 billion? We got £1.6 billion for the NHS and nothing at all for social care. But of course, we got £3 billion put aside for Brexit. How many doctors and nurses could we get for that?

It is clear that the overwork, stress and effective pay cuts suffered by our doctors, nurses and other health professionals will continue. These are contributing to their low morale and the fact that many of them want to leave, cut their hours or retire early. The public service pay cap imposed by the Chancellor for many years has not been lifted, despite a comment to the contrary by Jeremy Hunt. The small easing of the pay restraint announced by the Chancellor last week is conditional on the money being saved elsewhere by the removal of year-on-year increments of other health workers. It is all about saving money, not patient safety, yet patient safety is a big issue when you have demoralised staff working longer than they should in a team with vacancies. The Royal College of Physicians told us that 69% of doctors work on a rota with vacancies and that 74% of them are worried about the ability of their service to deliver safe care. Half of those polled by the RCP believe that patient safety has deteriorated over the past 12 months. What are the Government doing to ensure patient care?

What about nurses? The Royal College of Nursing has reminded us that, since 2011, nurses’ pay has dropped in real terms because their tiny pay awards have nowhere near kept up with inflation. No wonder trusts are having difficulty recruiting and retaining enough nurses and we now have 40,000 vacancies. So trusts are having to turn to expensive agency nurses—and things will get worse if Brexit ever happens. Indeed, it is happening already as some nurses from other EU countries go home and the number of applications to come here has fallen by 96% in the last year. UK applicants, too, are being deterred from training by the withdrawal of the student nurse bursaries.

Another fiscal measure that is demoralising nurses is the serial cuts to the budget for continuing professional development. This has gone from £205 million to £104 million, and now £83.49 million, over two years, so the opportunities for nurses to increase their income by undertaking specialist training are diminishing. Will the Government restore that funding for CPD and also look again at the bursaries for student nurses?

We are very dependent on doctors from abroad, including from the EU countries. We are not training enough of our own doctors. Despite the increase in medical training places by up to 1,500 per year by 2020, this simply will not do while we have rising demand and some doctors going back to their home country. It takes 13 years to train a consultant, so what are we to do in the meantime? Further funding for specialist training for home-grown doctors will be required, as well as an assurance to those who come to us from abroad that they are welcome here.

I have a particular concern about the cancer workforce. I have been involved in an inquiry by the All-Party Group on Cancer about where we are at this point, half way through the timeframe of the cancer strategy in England. Are we on track to deliver all the objectives or not? Although the report will not be published until next week, I think I can whet your Lordships appetites by revealing that all the evidence points to the fact that we are not. In particular, my colleagues and I were very concerned about the evidence of workforce shortages. We are still expecting the strategic review of the cancer workforce from Health Education England, which was promised a year ago. We were told it would come in December 2017, which starts tomorrow. I look forward to it. However, its delay has meant that the shortages which are apparent all across the NHS workforce are even more severe in cancer services because of the specialist staff needed to achieve the strategy. We heard that the lack of the staffing review, delays in releasing funding from NHS England and the last-minute changes in the criteria for transformation funding have meant that cancer alliances have not been able to plan properly and have certainly not been able to commit to funding staff posts until they are sure that they have the money available.

The cancer workforce is just one sector where, because of the clear objectives in the cancer strategy, it has been possible to measure progress against aspiration. However, we heard from several sources that workforce is the greatest challenge to delivering the strategy. I believe that fiscal measures could improve the situation here and right across the NHS, if only the Government were willing to put them into place.