National Health Service: Pensions Tax

Lord Balfe Excerpts

Wednesday 30th October 2019 Lords Chamber

Asked by

[Lord Balfe]

To ask Her Majesty's Government what assessment they have made of the impact on patients of doctors having to curtail their hours because of the rates of tax they would incur due to the pensions regime in the National Health Service.

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

My Lords, the Government recognise that pension tax may contribute to decisions by doctors to limit their NHS commitments. The NHS continues to work tirelessly to ensure that patients receive timely and appropriate care, so we are consulting on proposals to make the NHS pension scheme more flexible, so that doctors can continue to conduct vital NHS work while tailoring their pensions growth. The Treasury is also reviewing how the tapered annual allowance supports the delivery of public services such as the NHS.

[Lord Balfe (Con)]

I thank the Minister for her reply and draw attention to my interests in the register. This problem goes back to 2016 but, as of this week, the BMA, the doctors trade union, revealed that a recent survey showed that 42% of GPs have already reduced their hours spent caring for patients and 30% of hospital consultants have already reduced their hours. There have been similar figures from the Royal College of Physicians. Doctors are attracting massive tax bills as a result of working harder to care for their patients; indeed, half are now retiring younger. I am afraid that the appearance is of a dilatory Government where infighting between HM Treasury and the Department of Health is taking precedence over urgent action to deal with this problem. Will the Minister encourage the Government to get a move on and get this sorted out before even more patient time is lost?

[Baroness Blackwood of North Oxford]

I thank my noble friend for that very direct question. Our estimate is slightly different—that around one-third of GPs and consultants have earnings high enough to potentially be affected by the tapering of the annual allowance for tax-free pension savings. Not all clinicians are affected—it depends on the personal circumstances—but we accept that there is a need for urgent action in this area. That is why NHS employers have published guidance for short-term approaches that could have a mitigating effect on pension tax for the workforce this year and throughout the winter. We have also opened our consultation, which will close this Friday. We have already had 750 responses to it, and stakeholders are broadly supportive of the additional flexibility that has been proposed. We intend that flexibility to be available by April.

Obesity

Lord Balfe Excerpts

Wednesday 18th July 2018 Lords Chamber

[Lord Balfe (Con)]

My Lords, I thank first my noble friend Lord McColl for initiating this debate and, secondly, the noble Baroness, Lady Boycott, for her excellent maiden speech—clearly we have another person joining those interested in this subject. I declare my interests as the president of the British Dietetic Association, a TUC-registered trade union that looks after dieticians working in the health service. I can perhaps give my noble friend Lord Blencathra the answer to his question: how much red wine should we drink per day? I am informed by a doctor friend of mine that the figure is two units more than the doctor himself consumes and that, whichever doctor you ask, you will get the same answer.

I want to cover two issues in my brief allotted time. The first is the veracity of the numbers in the obesity debate. There is a great tendency today to exaggerate numbers, seemingly on the principle that the bigger the better. If noble Lords look at the House of Commons briefing on obesity, which has been circulated, 61.4% of all adults are obese or overweight. This may be true but it becomes a meaningless figure—many will say, “That’s all of us then, isn’t it? We don’t need to do anything about it”. I have some evidence that a BMI of around 26 or 27, which is technically overweight, has been shown as the best BMI for a longer life; we need to look at the figures. As the noble Lord, Lord McColl, would agree, BMI is an inaccurate measure anyway; the waist circumference to height factor is much better. We need to concentrate our resources on where the problem actually exists. Clearly the biggest problem concerns people with a class 3 BMI of over 40—those are the people who have real difficulty with weight problems. The second group are those with a class 2 BMI of 35 to 40. We tend to pepper-gun the problem, rather than dealing with it discretely.

I would like the Minister to go back to the department and look at the overall figures. Looking at the briefing—and this is confirmed in other briefings—we are asked to believe that obesity among children aged 10 to 11 is roughly 20%. On the exact same page of the briefing from the Library, we find that at 16 it is 11%. I do not believe the figure has dropped by 50% during those five years at school. It does not make sense. In Australia, the obesity level of 16 year-olds is 7%. The Minister needs to look at how these figures are put together.

My second point concerns the treatment of obesity. Clearly, current funding has been cut for local authorities. If we are to concentrate on the people who suffer from what I would call the top level of obesity, you need proper funding to do it. We have again—it is a bigger question—to look at how funding for health works. There is too much division between local authority, general practice and hospital practice; we need to look at joining them together.

I want also to talk about food and tax. The sugar tax is actually quite popular; I think any popular tax is a jolly good thing. I invite the Minister to initiate a few cross-party discussions on the extent to which sugar-laden goods and highly processed goods can be further taxed. If we can raise money for the NHS by taxing things—and being popular with it—I suggest that is a good thing.

Finally, I endorse what the noble Lord, Lord McColl, said about tooth decay. This is directly linked to sugar; it impacts particularly and very directly on five year-olds and is something we need to tackle. We cannot have a system in which the dental profession says 90% of decay is preventable, yet we do not have a strategy for it; I ask the Minister to look at a dental strategy.

Overall, the message I bring is that we need a good, well-targeted programme, particularly directed at gross obesity, rather than wringing our hands and saying, “Everybody’s too fat, but there’s nothing we can do about it”. We need a targeted programme. Please, Minister, look at these statistics.

Brexit: Reciprocal Healthcare (European Union Committee Report)

Lord Balfe Excerpts

Tuesday 3rd July 2018 Lords Chamber

[Lord Balfe (Con)]

My Lords, I begin by thanking the chairman and the members of the committee, of which I am not one, so I hope my intrusion will be forgiven.

On Thursday your Lordships will debate the 70th birthday of the NHS—it is just slightly younger than I am. Evidently it is one of the great post-war success stories but 45 of its 70 years have been spent inside the European Union. Over those 70 years, we have seen a continuing internationalisation of medicine and Europe working together more and more. I spent some 25 years in the European Parliament and represented the great teaching hospitals of Guy’s and St Thomas’ and had dealings with them from time to time. There was never a straightforward medical role for the European Union, but it was certainly involved in medical priorities.

The NHS is probably the best-loved child of the Attlee Government and probably a beneficial outcome of the Second World War. Throughout the Second World War, the first thing that people realised was that you had to have an efficient health service. You could not have people bombed out of their houses without adequate medical care. The predecessors of the NHS—people like Ernest Brown, the wartime Health Minister—did a lot to set down the parameters within which the health service has existed.

As we know, it is quite different from continental health systems. Having had a residence in Brussels for the better part of 40 years, I have had dealings with both the Belgian and French systems, which are pretty good and comprehensive. We see a lot of figures and tables, and I noticed one this morning in which we are just behind France in what we spend. However, they seldom take account of the insurance costs and the cost of running the insurance schemes. Every time you go to the doctor in Belgium, you do not pay much but you generate a lot of paper. You fill in a form; you part with €40; the doctor fills in a form to claim back the money; then you fill in a form to claim back about €35 of the €40 using yet another form which the doctor has given you. I am sure that the Minister will be aware of the cost of running an insurance-based scheme. It is certainly a factor which we need to keep in mind when we look at European schemes and how we can benefit from them. One direct benefit from the European Union that I was involved in was its funding of videos which were made by doctors at Guy’s Hospital in London who were doing certain operations, mainly on joints. These were then used to teach doctors in Portugal. It was remote learning of a kind which would now be done more easily with Skype, but even in the 1980s we had reciprocal healthcare and that has been quite a success story.

The NHS itself is a success story and one of the reasons for this is that the middle class supported it. It is a universal service and middle-class intervention has been quite crucial. This all leads me to the point that there is a lot of concern about Brexit and a desire that it should not impede the rights of citizens. If it does, there will, to put it crudely, be a lot of trouble. Europe is far too small not to have reciprocal healthcare arrangements. They are an absolute necessity. On page 6 of the government response to the report it states:

“The UK Government and the Commission have stated that providing certainty for citizens was a priority and we believe it would be unlikely for any deal on citizens’ rights agreed early on to be reopened”.


However, recommendation 4 states quite clearly that,

“nothing is agreed until everything is agreed”,

as we keep learning. In other words, it may be unlikely to be reopened, but it will be if there is no agreement. Leaving the EU without an agreement, as is the wish of some of the more extreme supporters of Brexit, would mean no healthcare cover for UK citizens abroad or for EU citizens here, presumably. I am quite sure that there would be a scramble to get some emergency measures in place, but that is not the best way of making public policy.

The noble Baroness, Lady Janke, referred to the interview with Simon Stevens on Sunday, repeated in the Times, which said:

“NHS prepares for no-deal drug and doctor shortage”.


The article outlined the problems potentially facing the NHS, including a worst-case scenario of hospitals running out of medicines in just two weeks, and the fact that it is now planning. Apparently 37 million packs of medicine arrive in the UK from the EU every month, with 45 million going back the other way. There is a very big common market in drugs. When Simon Stevens, CEO of NHS England, says that “extensive work” for a no-deal scenario is being done in collaboration with the pharmaceutical industry, I need to ask the Minister when he will be in a position to tell us about the nature of this extensive work. Although it is not his direct responsibility, has he been in contact with the devolved Administrations and are they also doing “extensive work”?

Paragraph 11 of the report’s conclusions asks the Government,

“to confirm how it will seek to protect reciprocal rights to healthcare of all UK and EU citizens post Brexit”.

In their response, the Government state that they want,

“a wider agreement with the EU on reciprocal healthcare into the future”.

Of course we do, but how are we going to get this alongside ending free movement? This is all part of a package. What is the status of current negotiations in pursuit of this wider agreement? Are they currently ongoing, and which department is in the lead—DExEU or Health and Social Care? Again, are the devolved Administrations involved, and how are they being co-ordinated?

Finally, it is clear from the briefings that I and other noble Lords have received that there is still much work to be done with regard to the position of reciprocal healthcare if the Government carry out their intention to end free movement. We need to prioritise access to reciprocal healthcare and we need a realistic assessment as to whether ending free movement is necessary or desirable. Simon Stevens has drawn attention to the fact that 10% of NHS doctors and 7% of nurses are nationals of other EU member states. This supply is apparently drying up because they do not have the confidence to come and work here. A solution is clearly needed, as is devising a retention strategy for the staff who are here.

I will make a prediction to the Minister. Being a bit of a cynic, I have said all along that Britain will end up in a Norway situation. We will be within the single market; we will have free movement, maybe with a minor concession at the edges; we will pay a very large bill; we will need extra staff in our embassy in Brussels to keep an eye on things. We will be represented at none of the meetings but will be subject to all of the decisions. That is the direction in which we are going. I finish with an absolutely true story. A year ago, I was in a ministry in Norway, talking to the Minister. He said: “You are going to find it is really difficult. We find it difficult in Norway, but at least we have got a direct line to Sweden and we are roughly the same size as them. Sweden and Norway have a long tradition of working together”. He went on to say: “The only other English-speaking country you have to fall back on is Ireland. Your relations are not quite as close with them, and there are a lot of problems that you are going to have to solve”. When we are outside the tent, so to speak, we are going to have far more difficulties in getting influence than Norway. I hope that I am wrong, but I fear I am right.

Children and Young People: Obesity

Lord Balfe Excerpts

Tuesday 17th April 2018 Lords Chamber

[Lord Balfe (Con)]

My Lords, I thank the noble Baroness, Lady Walmsley, for initiating this debate. I declare my interest in the register as president of the British Dietetic Association, which is the TUC-affiliated union that organises the 10,000 dieticians who work mainly in the National Health Service, and which is looking forward to meeting the noble Baroness, Lady Walmsley, whom it has invited to meet it.

I mention in passing that the biggest problem faced by dieticians is malnutrition among the elderly, a group that is often forgotten, but we welcome the government strategy on childhood obesity, published in August 2016, particularly the action to reduce sugar intake, such as the recently introduced sugar tax, and the guidance on the reformulation of high-sugar foods and calorie-reduction programmes.

I do not want to rain on the parade, as they say, but I would like to add a bit of context to the debate. The numbers are often misinterpreted. We often hear the fact that 65% of men and 58% of women are overweight or obese. That is because we like to confuse “overweight” and “obese”. They are two very different things. Only 27% of those people actually have a BMI in excess of 30—and, as the noble Lord, Lord McColl, will tell you, it is your weight, not your BMI, that matters anyway. But it is also notable that of the children who were obese, 48% of their mothers and 43% of their fathers said that their child was “about the right weight”, so it is not necessarily identified by the carers that they are obese.

I would like next to mention something from the Minister’s own department. The Minister has had a varied ride at my hands but tonight he might actually be pleased because in 2016, his department produced and published a study done by the Office for National Statistics. I am very fond of the Office for National Statistics, which often comes out with things that are rather controversial but generally held to be true. Let me read what it had to say about childhood obesity. It said:

“Compared with the general increase in childhood obesity from 1995 to 2005, the obesity rate has subsequently levelled off. The prevalence of childhood obesity has varied little in recent years. This is consistent with international evidence that childhood obesity rates in developed countries are stabilising and that they may be declining”.


That is our Office for National Statistics, which generally gets it right. Even for parents, while there has been a gradual drift upwards, it said that,

“the trajectory of overweight and obesity has plateaued, as there has not been a statistically significant increase since 2010”.

Those are ONS figures in an ONS report published by the Minister’s own department, so I am just saying that we need to keep it in context.

That does not mean to say that we do nothing because clearly there are problems and we need to address them. In particular, and I rely on the British Dietetic Association for this as my own family experience is somewhat out of date, there is the promotion of breast-feeding. Dieticians have much evidence that this has a protective effect against obesity and cardiovascular disease in later life; therefore, the BDA strongly recommends that HMG’s obesity strategy should include initiatives to promote and encourage breast-feeding. I am sure that that is correct.

We also look for strong controls on the promotion, marketing and advertising of unhealthy food and drink, with particular attention given to limiting price promotions. These are apparently much more prevalent in the UK than in other European countries. Public Health England has shown that price promotions increase the amount that people buy by around 20%, and the amount of sugar purchased as part of these foods by around 6%. There is also a school of thought, supported by the BDA, that advertising should be restricted until after the 9 pm watershed. I take the point about leaving the EU but Scandinavia has a pricing policy which basically forbids predatory pricing. In other words if something is 200 grams in weight, it should cost twice as much as something that weighs 100 grams and not one and a half times as much. That policy could be introduced.

There is no magic bullet in this area. There clearly is a strong link between poverty and obesity. Twice as many children in the lowest 20% are obese as in the highest 20% and we look to address this. What I am saying is that if we can keep the problem in perspective, we might find solutions. If we constantly look for high numbers that look good on the front of newspapers, the likelihood is that we will not solve the problem but go away, throw our hands up in horror and say, “It’s too big for us to do anything about”. Within reason, we have a chance of solving this problem and moving forward.

Brexit: Health and Welfare

Lord Balfe Excerpts

Thursday 29th March 2018 Lords Chamber

[Lord Balfe (Con)]

My Lords, I add my congratulations to the noble Baroness, Lady Brinton, on securing this timely but unfortunate debate. It is unfortunate because of the position we are in vis-à-vis Europe and the worst political decision of my lifetime—and I have been around for quite a long time.

You learn something every time you have a debate. I did not realise that my noble friend Lady McIntosh had a connection with Hamburg. My late father-in-law was on the control commission in Hamburg when my wife was born, so we also have a family connection.

I declare an interest as president of the British Dietetic Association, a trade union with most of its workers within the National Health Service and workers from all over Europe. I was also for some years, while David Cameron was around, the envoy to the trade union movement and, in that context, I came across the BMA, a noble trade union. I was once asked who I would choose if I needed to negotiate. I said that, as the general-secretary, I would have only two choices to negotiate for me: Hamish Meldrum, who was the general-secretary of the BMA and probably the most effective negotiator in the trade union movement; and the late Bob Crowe, who was also extremely good at getting benefits for his members—and “sod the politicians”, as he once said to me.

I wish to deal with three of the BMA’s concerns, one or two of which have been alluded to but not completely. The first concerns the register of doctors’ fitness to practise and the internal market information system, which is part of the wider directive. This system allows the GMC and medical regulatory authorities within the EU to communicate with each other when a doctor has his or her practice restricted in one or other of the 27 member states. In other words, it is a key safety feature. It will be important to consider how health regulators can ensure that professionals practising in the UK after we leave can get access to this register, should we withdraw. It is a fundamental safety issue. My question to the Minister is simple: do the Government agree that, to avoid the risks to patient safety, it is vital that the General Medical Council retains access to this system? Will they help towards the achievement of that important point? Euratom, which is vital in medicine because of the quick half-life of many nuclear isotopes, has also been mentioned.

Many have said that the British people did not realise what they were voting for. I think they simply voted to get rid of foreigners—an appalling reason for voting. Were it left to me—nothing is, these days, because I am so off message—I would tear the whole thing up, frankly. I would say, “Look, you’ve got it wrong. Have another try”. The Government did not even realise that we were going to leave Euratom; then, because they have a paranoid fear of the European Court of Justice, they decided, “Oh, we’d better leave Euratom as well”. This is sheer madness. The UK relies on supplies of nuclear radioisotopes and their quick delivery. Hospitals in Britain depend on these isotopes crossing the border, and doing so swiftly. They have a very short half-life and they cannot be stockpiled; we cannot just buy a year’s supply of them. Will the Government seek a formal agreement with Euratom to ensure consistent and timely access to radioisotopes for medical purposes? It is crucial.

My third point is on European reference networks, known as ERNs, which have been set up,

“to enable health professionals and researchers to share expertise, knowledge and resources on the diagnosis and treatment of complex and rare medical conditions … There are 24 networks, involving over 900 medical teams”,

around the European Union and “more than 300 hospitals” are involved in this network. I fully share the contention that it is essential that we continue to have ongoing access to and participation in the European reference networks. This will ensure that healthcare providers across Europe can tackle complex and rare medical conditions, which often require highly specialised treatment, and patients will continue to receive the best possible care. This is crucial. Medical knowledge benefits from interaction, not getting wrapped up and living in some little hole called—I was going to say, “some little hole called England”, but that is not very flattering to our country.

It is not done in this House to refer to Members of the Opposition as “my friend”, but I will make an exception in referring to the Member of the other House for Cambridge, Daniel Zeichner, as a good friend and someone who has consistently stood by the European ideal. Even when it is a curse to his future, he has been unwavering. One of the things that Daniel has recently brought into the public domain is the problem of getting workers into the UK. This goes away from the EU dimension slightly; we have a problem with EU workers but also with non-EU workers. As those of us who have studied these things know, or have learned from others, tier 2 visas are applicable to workers from outside the EU. In the city of Cambridge, where I live, Addenbrooke’s Hospital—one of the world’s leading hospitals—is not only short of key workers but has been refused permission to employ key workers who are waiting, need a job and are ideal for the job, because the tier 2 ceiling has been reached. They have been turned down not once, but in December, January and February. I put it to the Government that not only do they need to make it easier for UK hospitals to employ European workers but we need to look at tier 2 visa requirements. In the United States and Canada, very skilled workers can be employed with an underwriting by the employer. I am hoping to dispatch my son to the United States soon; under its system, there is no problem in getting a visa if the company will back the employment of the person. I put it to the Minister that we need to look at this issue. We need not only to make life simpler and easier for other EU workers, but to look at the tier 2 regulations.

My final point is this: we often talk in this country as though there is some great horror in having foreigners among us—that we need more UK this and UK that. Quite bluntly, I do not want a totally UK workforce. We benefit from the diversity of Europe—the different skills, attitudes and cultures that come into this country. I would regard it as an absolute disaster if we went back to the England I grew up in. Britain today is a much better place because of the huge number of different cultures and people who have come in to make this country. It is a great country because it is mixed and open, one that people want to come to live in because they get a fair crack of the whip. What I would say is—apart from “tear up this whole silly notion”, but assuming we cannot do that—for goodness’ sake, let us make it possible for this to be an open society, and start off in the medical sphere.

Older Persons: Human Rights and Care

Lord Balfe Excerpts

Thursday 16th November 2017 Lords Chamber

[Lord Balfe (Con)]

My Lords—

[The Deputy Speaker (Baroness Andrews) (Lab)]

The Question is that this Motion be agreed to.

[Lord Balfe]

I shall try to get it right this time.

I draw attention to my entry in the register and congratulate my fellow member of the Council of Europe, George—the noble Lord, Lord Foulkes—on tabling this Motion. As he rightly said, his report was adopted unanimously, which means, of course, that our side voted for it as well. I also welcome the noble Baroness, Lady Thornton, back to the Front Bench, where I am sure she will continue to make a distinguished contribution.

As many noble Lords know, I have spent far too long in Europe and probably spend far too long following what is going on. I was interested to see that this Friday in Gothenburg there is a meeting of the Social Affairs Council to discuss social rights and the 20 principles of social rights. The Commissioner, Marianne Thyssen, has indeed said:

“We go for a Europe where our citizens come first”.


I only mention that in passing because this is yet another thing we will lose when we leave the European Union. We will no longer be part of these conversations and discussions on how to get best practice.

The report we are discussing talks about ensuring,

“appropriate assistance and support for older persons living in their homes, including medical and nursing care, meals on wheels and domestic assistance”.

I regret that, of all the briefings we have received for today’s debate, none has come from UNISON, the major trade union involved, or other representatives of what one might call the workers. Indeed, the only document I have received, which is a very valuable one, is an article from the Institute of Employment Rights on why collective bargaining is needed for workers in this sector. We often forget how many people work in social care. It is 1.1 million, the same number who work in all the pubs, restaurants, bars and cafés in England put together, but these are an unsung army. These are the people you see at 5.30 in the morning by the bus stop, going to help to get people up. They are the backbone of the social care system in this country, but sadly they often go unrecognised. Part of the reason for that is because it is very difficult to enforce individual rights if you are basically a lone employee of a privatised service.

I know that we have saved lots of money through privatisation but we have also saved much of it at the expense of the people right at the bottom of the pile—the people who dare not claim their holidays and who are afraid to put their head above the parapet because it could mean the end of their job. I do not think my next point is a party one because I think that we have both been as bad as each other, frankly. I want to hear us say that although this work is individual in nature, we need individual rights that are easier to enforce. We have one of the weakest law enforcement structures in relation to the rest of western Europe, and we have gone backwards. If noble Lords go back to the much underrated but signal figures of the Conservative Party, Stanley Baldwin and Neville Chamberlain, they will see that, during the 1920s and 1930s, with the erection of wages councils, the protection of certain groups of workers came right to the fore—and stayed there until the wages councils began to be dismantled in the late 1970s.

We need a central collective bargaining mechanism which lays down basic principles for workers within this specialist field. The issue is not just about the minimum wage; there are also questions about, for example, sleepover allowances and casualisation. When we are told that employers cannot afford to pay the minimum wage, my reaction is that there is something wrong with the system, not with the employers.

I appeal to both parties to look at the need for a system of collective bargaining and responsibilities—an end to the excessive casualisation of this sector and an acceptance that care for the older person, which is the heart of this report, has also to include respect for the carer, who puts so much into making life reasonable for many older citizens. We have a duty to them. I thank the noble Lord for introducing this report, which enables us to look at a very wide range of problems.